HomeMy WebLinkAbout01-4659
POST & SCHELL, P.C.
BY: AMY L. CORYER, ESQ.
J.D. # 82718
240 GRAND VIEW AVENUE
CAMP HILL, PA 17011
(717) 731-1970
ATTORNEYS FOR PETITIONER
NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY
NATIONWIDE ASSURANCE COMPANY
d/b/a COLONIAL INSURANCE COMPANY
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,
PENNSYLVANIA
Petitioner,
v.
CIVIL ACTION - LAW
C:lu;L ~~
NO: 01 - J.i1..SC1
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, Individually, and as Parents
and Natural Guardians of CASEY
HIPPENSTEEL
Respondents.
PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION
AND NOW, comes the Petitioner, Nationwide Assurance Company d/b/a Colonial
Insurance Company, by and through its attorney, Post & Schell, who files this Petition to
compromise action for approval of settlement and aver the following in support thereof:
1. Petitioner is an insurance company who writes business in the State of
Pennsylvania.
2. Respondents, Gary Hippensteel and Dianna Hippensteel, are adult individuals
currently residing at 243 Neil Road, Shippensburg, Cumberland County, Pennsylvania, 17257.
3. Respondents, Gary Hippensteel and Dianna Hippensteel, are the parents and natural
guardian of the Minor, Casey Hippensteel, who resides with the Respondents at the above-noted
address. See Affidavit of Parents attached hereto as Exhibit "A".
4. This petition is filed as a result of injuries sustained by the Minor child, Casey
Hippensteel, as a result of an automobile accident that occurred on February 16, 2001.
5. The Minor child, Casey Hippensteel, sustained a laceration to the forehead, a
sprained right ankle, and soft tissue injuries to her neck, back and left shoulder. See copy of
medical records attached hereto as Exhibit "B".
6. At the time of the accident, the Minor child was under the majority care and control
of the Respondents.
7 . Petitioner has made a careful and diligent inquiry and investigation into the facts
surrounding the accident, the responsibility therefore, and the nature, extent and seriousness of
the Minor child's injuries.
8. All of the Minor child's medical bills have been paid.
9. The Respondents, Gary Hippensteel and Dianna Hippensteel, carried a policy of
insurance with the Petitioner, Nationwide Assurance Company d/b/a Colonial Insurance Company,
on the date of loss with unstacked Underinsured Motorists Benefits with limits in the amount of
$15,000 per person. See declarations page with rejection of stacked underinsured motorists
benefits form attached as Exhibit "C".
10. The Petitioner, Nationwide Assurance Company d/b/a Colonial Insurance
Company, has agreed to compromise this Underinsured Motorists claim for the policy limits of
Fifteen Thousand and 00/100 ($15,000.00). The $15,000.00 is being paid to purchase a structured
settlement which will result in a total payment of Twenty Thousand Three Hundred Dollars
($20,300.00) to the Minor Child, with a lump sum payment of Five Thousand Three Hundred
Dollars ($5,300.00) to be paid on or about August 6, 2004, and Fifteen Thousand Dollars
($15,000.00) to be paid on or about August 6, 2007. It is a fair and reasonable resolution under
the circumstances. See Exhibit "D".
11. The Respondents, Gary Hippensteel and Dianna Hippensteel, understand and
approve the settlement achieved. See Exhibit "A".
12. The Respondents, Gary Hippensteel and Dianna Hippensteel, have executed both
a Release Agreement and a Uniform Qualified Assignment and Release, copies of which are
attached hereto as Exhibit "E" .
WHEREFORE, Petitioner prays that an Order be entered approving the Minor's
Compromise and ordering that distribution pursuant to the Court's Order.
Respectfully submitted,
POST & SCHELL, P.C.
DATE: 'iI,lol
(1,(1 d (l~P1
AMYL. ORYER SQUIRE
Attorney for Petitioner
CERTIFICATE OF SERVICE
I, Sharry D. Semans, an employee of Post & Schell, P. C., do hereby certify that on the date
listed below, I did serve a true and correct copy of the notice of deposition upon the following
person(s) at the following address(es) by sending same via United States mail, first-class, postage
prepaid:
Gary and Dianna Hippensteel
243 Neil Road
Shippensburg, PA 17257-9403
Respectfully submitted,
POST & SCHELL, P. C.
DATE: S/;;./O(
BY .1:~~~~
Exhibit A
AFFIDAVIT OF PARENTS
In the Commonwealth of Pennsylvania:
County of Cumberland:
Gary Hippensteel and Dianna Hippensteel, being duly sworn according to law, depose and
state:
1. We are the parents and natural guardians of the minor, Casey Hippensteel.
2. We have reviewed and approved the Petition for Leave to Compromise Action on
Behalf of a Minor and the Order Approving Minor's Compromise for Distribution and concur with
the distribution.
~, ~~42pu .~
GA HIPPEN TEEL ~~
JU1~/It1 ~--~
DIANNA HIP EN EL
Sworn to and subscribed
before me this /? day of
J(,Llt ,2001.
}flhNJA-lilJ ;t;tQA )
Notary Seal
NOTARIAL SEAL .
DEBORAH WARREN, Notary Pubhc
Shippensbu~9, sun;berl~d C8ou;~1
My commlSSI?~_.C~p.\~~~." oV:u"'._'
Exhibit B
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HOSPITAL
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ADM NURSESSTN
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TELEPHONE NO MEDICARE SECONDARY PAYER INFO.
(7171532-5538 1. N 2. N 3. N 4. N 5. N 6. N
ADMIT BY
TSK
An affiliate of Summit Helll/I,
NAMEANDADDAE5S
HIPPENSTEEL. CASEY M
243 NEil ROAD
SHIPPENSBURG, PA
17257
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TWP/CTY 430 CUMBERLANlDJO PRECERT
t1tis DATE ADMITTED TIME AGE
14 02/16/01 16:19
PUBLISH A TrENDING PHYSICIAN
MARITAL DATE OF BIRTH
STATUS
S 08/06/86
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INPATIENT ADMISSION
CHAR~
SOCIAL SECURITY NO.
170-68-5077
ADMISSION NO.
318215-1
SECONDARY INSURED EMPLOYER
RELlGION-CLERGY-CHURCH
N
GORMAN MD, RICHARD E
53052
7
ADMISSION SDURCETYPE
NO CHURCH AFFILIATION
WORKMAN'S COMP, ACCIDENT DATE
PERSON TO NOTIFY IN CASE OF EMERGENCY
DIANNA
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NAME AND ADDRESS
HIPPENSTEEL, DIANNA
243 NEil ROAD
SHIPPENSBURG. PA 17257
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INSURANCE COMPANY
NATIONWIDE MUT INS
FAMilY CARE NETWORK
PLAN CODE
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3030
POLICY HOLDER
HIPPENSTEEL. 01
HIPPENSTEEL, CA
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SECOND PERSON TO NOTIFY IN CASE OF EMERGENCY
NONE GIVEN
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Federal law requires us to ask you the following:
1. Do you have a living will? NO
If yes, copy on chart?
2. Do you have a durable pow~torney for health care? N ()
If yes, copy on chart? _
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Permission To Place Name on Assignment Board
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Signature
n 'An Important Message from Medica:~'?"
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Chambersburg Hospital S ff Member/Work Area
02/16/01
MUl T TRAUMA
RELATION TO PATIENT
MOTH
PRIMARY INSURED EMPLOYER
AM UNEMPLOYED
SOCIAL SECURITY NO.
205-44-0537
REl. POLICY/CERTIFICATE NO.
03 58370357191
01 5301039946
GROUP NO.
ACCESS
PRIMARY INSURANCE ADDRESS
A TTN: MEDICAL CLAIMS 14
HARRISBURG. PA 17106,9600
SECONDARY INSURANCE ADDRESS
MEDICAL ASSISTANCE 19
HARRISBURG, PA 17105
3. Do you have an organ/tissue donor card? -.N.Q.
If yes, copy on chart? _
4. Are you interested in organ/tissue donation?
5. living will/organ donor information offered to patient? _
D'te .q - le.(;!
Time
1950
o No
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ACKNOWLEDGEMENT OF RECEIPT--My signature only acknowledges my receipt of this message from Chambersburg Hospital on the date listed above and
does not waive any of my rights to request a review or make me liable for any payment.
Signature
Patient Signature
REFERRING PHYSICIAN
CONNOR DO E. J MICHAEL
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FAMILY PHYSICIAN
UNKNOWN.
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.IlbamberSburg.
, Hospital
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112 Norlb ScmJtb Street . P.O. Box 600S
~ PA 17201-6005 . (111)267-3000
DISCHARGE/ATTESTATION OF DIAGNOSIS
PRlNCIPAL DIAGNOSIS (reason for admission after study) list one:
JrJf/(, ;f!-t,t..------zf.--
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OTHER diagnosis and/or complications (all conditions that co-exist at the time of admiSSioG(t..h.at develo~ subse-
quently, or tbat affect the treatment received and/or the length of stay): (' ()( 0,/
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OPERA nONS
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Summary dictated:
DYes
[]-No
DISCHARGE ORDER
[j-Home 0 AMA
o Expired
o Transfer to:
o ECF
o Hospital
o Other
I certifY that the narrative descriptions of the principal and secondary diagnoses and the major procedures performed are accurate
and complete to the bes of my knowledge. ~.4' ~~ '
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Physician's Signature/Date ,.
EEL CA.SE'I' \\11269/01
I-\tPPEN~J215- { Rrn/seg';,: 002/16/01
I'-cct: 3. 33 I'-drn \-\1'-1\0 E
MR#: 51 B~I\\\III'-N \\liD, I\~ Sex: F
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DISCHARGE INSTRUCTIONS
112 North Sl::v~nlh Slfc~t . P.O. Box 6005
ChambersbuT1;. PA 17201-6005 . 0(7) 267-3000
ALLERGIES:
CHEK-MED
CARD GIVEN
NEWiCHANGE
MEDICATION
MEDICATIONS
DOSE
FREQUENCY
Prima? Doctor's Appointment:
Dr. v(};Lr--z..~
C{14. (/
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phone: 2-/7 -(,tfOD
ADDITIONAL INSTRUCTIONS
APPOINTMENTS
ConsuRation Appointment:
Dr.
phone:
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Activity: f~ ~nr,'Y'.."V (;l~~lv-r,,~
Any driving restrictions: 0 yes 0 Ino (if yes, the patient
was advised not to drive for _ hours or days) (circle one)
Diet:
HIPPENSTEEL, CASEY M
Acct: 318215-1 Rm/Bed: 0269/01
MR#: 518233 Adm Dt: 02/16/01
Doctor: ,GORMAN MD. RICHARD E
DOB/Age: 08106/86 14Y Sex: F
Notify: DIANNA 7175325538
o No Restrictions
~rinted Instructions Given
I CALLlN EMERGENCY:
2--/7' - C/,6()
I read a d understand these instructions:
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WHITE COPY - CHART YELLOW COPY - PATIENT PINK COpy - PHYSICIAN
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R: 4/95
P03348
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THE CHAMBERSBURG HOSPITAL
112 N. Seventh St.
Chambersburg, P A 17201
DISCHARGE SUMMARY
HIPPENSTEEL, CASEY M.
R. E. Gorman, M.D.
Medical Record #: 518233
Admission Date: 02/16/2001
Discharge Date: 02/17/2001
ADMITTING DIAGNOSIS: 1.
SPECIFIC DIAGNOSES: 2.
3.
Multiple trauma secondary to motor vehicle accident.
Laceration to the forehead.
Multiple contusions and abrasions.
HISTORY: This is a 14-year-old female, unbelted, rear seat driver's side passenger who was T-
boned in a motor vehicle accident which subsequently struck a telephone pole on the driver's
side. She lost consciousness and she has amnesia related to the events of the accident. Her vital
signs were stable in the field and en route. She was complaining on admission of some pain in
her head, her left shoulder, her back throughout the thoracic and lumbar regions. Her past
medical history is significant for asthma. Medications include Singulair and Albuterol.
Physical examination: She was awake and alert and in no distress. Vital signs were stable.
HEENT: There was noted to be a laceration on her forehead, just beneath the hairline extending
transversely that goes deep down to but not through galea. Pupils were equally round and
reactive. TMs were clear. Neck was supple, minimally tender posteriorly. Lungs were clear.
Heart was RRR. Abdomen was soft without masses. Pelvis stable. Rectal: Guaiac negative. On
examination she is noted to have an abrasion of the left shoulder and left knee. Point tenderness
in the medial aspect of the right ankle. Neurologically she was grossly intact.
'LABS: Amylase was 98; white count elevated at 16,000. Beta HCG was negative. X-rays: Chest
x-ray, pelvis x-ray, C-spine films, thoracic lumbar films, ankle films, CT scan of head, facial
bones, abdomen and pelvis all were negative.
HOSPITAL COURSE: The patient was admitted. In the Emergency Room she underwent
.
repAir Mthe laceration of her face by myself. She was kept under observation and was
discharged the following day with prescription for pain medications and to follow-up with me in
the office in a week.
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REG/TK:las/268881
D: 02/26/2001
T: 02/27/2001
R. E.
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EMERGEI\~ARE UNIT
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Registration Data Sheet
CHART COPY
CI-iAMBERSBURG
HOSPITAL.
An affiliate of Sum mil Herlllh I SERVICE CODE I METHOD OF ARRIVAL I CLERK'S INITIALS I ACCOUNT NO. In: 1 MEDICAL RECORDS NO.
75 AMB MED TSK 3182151 518233
NAME AND ADDRESS TELEPHONE NO. PATIENT OCCUPATION/EMPLOYER NAME & ADORESS - PRIMARY TELEPHONE NO
HIPPENSTEEL, CASEY M (717)532-5538
243 NEil ROAD UNEMPLOYED EMPCOOE:
0
"- SHIPPENSBURG, PA 17257 '" 170-68-5077
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.... PRECERT INFO: NO PRECERT
2 FIN sl QA TO. OF SERVICE I"M' I I AGE JATO. OF BIRTH I s~' IRACEW MARiTAL I NEXT OF KIN/PERSON TO NOTIFY (INFO)
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;: etA" STATUS DIANNA MOTH 7175325538
<t 14 02/16/01 13:00 14Y 08/06/86 S
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SPECIAL INFO IDee. coDe DATEOFOCC I MEDICARE SECONDARY PAYER INFORMATION
01 021601 1.N 2.N 3.N 4.N 5. N 6. N
NAME AND ADDRESS RELATION TO PATIENT RIP OCCUPA liON/EMPLOYER NAME & ADDRESS. SECONDARY
W HIPPENSTEEL, DIANNA
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20:
0<( TEL NO (7171532-5538
ll;"- SHIPPENSBURG, PA 17257
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INSURANCE COMPANY PLANCaDE POLICY HOLDER REL. PDUCY/CERTIFICATENO. GROUP NO.
'" NA TIONWIDE MUT INS 4014 HIPPENSTEEL, 01 03 58370357191
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2 MEDICAL ASSISTANCE 3000 HIPPENSTEEL, CA 01 5301039946 ACCESS 37
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NOTES:
Registration Receptionist
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~. :ERGENCY CARr' 'IT RECORD . .. .
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DTeaching Physician present for key port proc + Eval Management Plan N I (if yes, place a green dot on ch{rt.L.-
HPI 4: LOCATION SEVERITY TIMING MODIFY FACTORS --
QUALITY DURATION CONTEXT ASSOC SIGNISX
ROS 10: GEN ENT CV GU SKIN OALL OTHER RaS
EYES RESP GI M-S NEURO REVIEWED+ NEG
o MEDS EXAMS VSfGEN HEART M.S
o ALLERGY EYES LUNGS SKIN
o CAVEAT ENT ABO NEURO
MEDICAL DECISION MAKING (MOM)
DMDM 4:DX AND + WORKUP OR 2 + OX
DMDM 4: 1 POINT - LAB, XRAY, OLD RECORDS I HX FROM OTHERS
2 POINTS - READ EKGI XRAY, SUMMARIZE OLD RECORD.
DISCUSS CASE WI OTHER MOIDO
o MOM: DIFFERENTIAL -INCLUDE HIGH RISK
~ oTEST RESULT OIMPRESSION (SYMPTOMS,SIGN,DX)
n 0 ED COURSE 0 DISPOSITION
KN~E fo,'1J/!t( PORTC>(.Rf- OLD RECORDS:
FEtv~ PAILATCXR o INPATIENT
DECU
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ECU Doctor \ ?gt. -J..;Jictated
Time Seen ~ DCC Time=
min
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CARDIAC PACK CBC URINE C&S
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.. PSYCH PACK ~MP '-' GC
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- TRAUMA XRA Y CPMP CHLAMYDIA
~ PED PROFilE AMYLASE SPIRAL CT
0; DIGOXIN lEVel PT o CT H~oIt\.
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THEOPHYlliNE LEVEL PTT
DILANTIN LEVEL SERUMJURTOX.SCR. 0' ~NKlE I KI. "-
ETCH STREP SCREEN TIB/FIB --
HIP AAS
HAND ,X PORT PE~
WRIST PELVIS
FOREARM X PORT C-SPI~~
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SHQUL C-SPINE r-\f'\
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MED PREPACKS
VICODIN - eTG _ pO q 4 hr prn pain
KEFLEX 250mg - 1 po qid
ROBITUSSIN AC cc TG, _tsp po q 4 hr
GENTICID1N DROPS -9tts OD/OS qid
FLEXER1L 1 po tid prn spasm
po q 4 hr with food pm pain
TYLENOL #3
TYLENOL #3 ELIXIR _cc TG, ....:....-tsp q 4 hr prn pain
PERCOCET - 4TG - 1po q 4 hrwith food prn pain
DARVOCET - 1 po q 4 hr with food pm pain
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~ther/Emergent
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Referral Physician's Signature ..... Discharge Time
E~'vnt,,'e_7f(;:::~f ~meE:
Dale Family Doctor I
02/16/01
Referred To
Physician's Signature
Name: HIPPENSTEEL, CASEY M
Phone: (717)532-5538
Ace! No: 318215-1
.
M R No: 518233
Age: 14Y DOB: 08/06/86
I~erred to Doctor
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Time
F
Sex:
13/Y
13:00
CHART COPY
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HEMATOLOGIC
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LAB REPORT
OLD RECORDS REVIEWED
NURSING NOTESNS REVIEWED
HX OBTAINED DSPOUSEOFAMll
Td 0.5ee II OOTHER
VIS GIVEN PRIOR TO Td
ACE
AIRCAST
CRUTCHES
SUTURE REMOVAL
STERI STRIPS
DRESSING
FOAM METAL SPLINT
UNIVERSAL SPLINT, METAL
OCl
SLING
KNEE IMMOBILIZER
NEW PHYSICIAN LIST
ORTHO VS
AMOXIL 250 mg . 1 po lid
AMOXIL 125mg/5cc tsp po tid
AMOXIL 250mg/5cc tsp po lid
BACTRIM OS - 2TG . 1 po bid
BIAXIN - 500mg - 1 po bid
o Discharge
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Admit room N~ ~7
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CHAMBERSBURG
HOSPITAL
An I.lf!iliule flfSummif HeaM
Chambersburg. PA
P00090 (0:eI97,R:4/00)
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Date Triage Time Triage Priority 2-11/ Room I
J,)lu/ol \;'0$
Chief Complaint: Vital Signs Arrival Mode:
(1Jk O....L-L.. c;J-.J ~ Time T P R BP 02 sat%
I Pain Score - ~. OWalk OW/C
HPI Triage Z Jd1<CS ...Q-gLS
L~vhv..-\- OflJ~'2A/~1h L., Jv.".,( ~."" ~ 1\_11 116 '/.;1-- q1 o Carried o Police
. ,'.) &)LOL
( 1N\.P;7 -/.ilA i ,'^'A .S1J o Other
(~Sh(}J-llck. ()[M. .... . bA t.,L OW f\ Info provided by (if other than patient):
o Family o Other
(~) -Jr I Language spoken other than English:
c...........
Airway/Breathing Mental Status Speech
Other concerns DNa ~le to speak ~ert ~ormal
o Assisted o Onented X [] Aphasic
o Labored o Unresponsive o Slurred
PMH: PSH: o Shallow o Confused
o Apneic
o None o None
~~tis o Appendectomy Behavior Conversation Ideation
Asthma :J Cardiac ~perative .aNA (Not Applieable)
DCA o Cholecystectomy ~herent
o Cardiac o Hysterectomy o Uncooperative o Silent o Harmful to Self
o COPD o Other OB/GYN o Calm o Overtalkative o Harmful to Others
OCVA o Prostate o Agitated o Incoherent
o Diabetes i:J Tonsillectomy o Violent Q Crying
o Hypertension o Hernia repair
o Psychosocial 0 Visual Acuity:
[] Seizures
o Smokes 0 OS 00
o Substance Abuse o Corrected o Not Corrected LMP \NT
0
~~s: Ped Immunization:
0 ithin 5 yrs o Never OUTD
[] >5 yrs o V!S given prior to Td o Not UTD o VIS given prior to Td
Medications, Herbs, & Vitamins: o None o Unknown Last Dose
^ Emotional/ Safety / Religious. Issues:
t\ l ~-1e~ DNa o Domestic Violence / Abuse Referral
DYes o SS Referral
o Chaplain Referral
\'1'1\ <v-f'", ,^-- DYes QNo Age appropriateness RIT Growth and Development < 17 years
j i.JN/A
PRE-HOSPITAL CARE: ON/A
Vital signs: BP p. Rhythm: R:
Oxygen Airway: o Nasal o Oral
. o ET Tube # Taped @ em
o Cervical Collar ALS MEDS
Allergies: /' Reaction: o Longboard o Albuterol med neb o Atropine
OCID o NTG , o Epinephrine _
o Splint o Lasix o Lidocaine
o CPR Begun @ o Morphine ~
o Blood Sugar o Deitrose 50%
~)C~ OI.V. o Other
Triage RN - Y-
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Signature
HIPPENSTEEL. CASEY M ECU Triage Assessment IIham~~;~~rf~,~
Acct: 318215-1
MR#: 518233 112 North Scvemh Street. PO. Box 6005
Date: 02/16/01
DOB/Age:08/06/86 14YSex: F ChJmbcrsburg, PA 17201-6005 . (71,7) 267-3000
Patient Phone: (717)532-5538
White - Chart Co Yellow - Ph sician Billin POOOB4C O:4/00}
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THE CHAMBERSBURG--r!OSPIT AL
112 N. Seventh St
Chambersburg, P A 17201
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Page 1
EMERGENCY CARE UNIT
(717) 267-7146
HIPPENSTEEL, CASEY M
Patient #: 3182151
Treatment Date: 02/16/2001
J. M. Connor, D.O.
Medical Record #: 518233
Patient Type: 2
D.O.B: 08/06/1986
CHIEF COMPLAINT: Motor vehicle accident
HISTORY OF PRESENT ILLNESS: This is a l4-year-old female who was a rear seat, behind
the driver, passenger in a motor vehicle accident The driver apparently ran a stop sign and the
car was T -boned on the driver's side. It was then pushed into a telephone pole, The patient does
not recall the accident She had apparent loss of consciousness. She was transported to the
emergency department on back board and CID. She complains of pain to her entire back, left
side of her face, her neck, her left knee and her right ankle,
PAST MEDICAL HISTORY: Significant for asthma.
PHYSICAL EXAM: Saturations are 99% on room air, blood pressure 125/56, respiratory rate is
22, pulse 120, temperature 97,6. Examination of the head reveals an approximately 6 inch
laceration over the mid forehead at the hairline. It extends full-thickness. Pupils are equal and
reactive to light Extraocular movements are intact The neck has some tenderness in the right
paraspinal muscles. Thorax has some bruising over the left side of the chest No subcu. or
crepitants, The lungs are clear. Cardiovascular is regular rate and rhythm. The abdomen is soft
with mild tenderness. No localizing pain, Pelvis is nontender to rocking. The right lower
extremity reveals pain in the right ankle and pain in the left knee. No obvious deformities with
mild bruising present The upper extremities show no obvious trauma.
DIAGNOSTIC STUDIES: Portable chest, pelvis and C-spine show no significant
abnormalities. CT of the head to evaluate the swelling and periorbital ecchymosis over the left
orbit are pending. White count was 16.2 with a hemoglobin of 13.4 and hematocrit of 40.
Pregnancy test was negative. Urinalysis was negative. Drug screens were all negative.
DIAGNOSIS: I. Multiple trauma from motor vehicle accident
2. Facial trauma,
3, Scalp laceration.
..
TREATMENT: Immediate general surgery consultation was obtained on arrival to the
emergency department The patient had CT of the head and facial bone, CT of the abdomen and
-.,
...-..-
THE CHAMBERSBURGTIbSPIT AL
112 N. Seventh St
Chambersburg, P A 17201
Page 2
EMERGENCY CARE UNIT
(717) 267-7146
HIPPENSTEEL, CASEY M
Patient #: 3182151
Treatment Date: 02/16/2001
J. M , Connor, D,O.
Medical Record #: 518233
Patient Type: 2
D.O.B: 08/06/1986
pelvis and plain x-rays of the involved extremities, The patient will be subsequently admitted to
Dr. Gorman's service for continued care and treatment
~
JMC/r1r
D: 02/16/2001
· . T: 02/17/2001
J. M. Connor, D.O,
cc:
THE l.tfAMBERSBURG-rlOSPIT AL
112 N. Seventh St.
Chambersburg P A 17201
Page r'
IDSTORY & PHYSICAL EXAMlNATION
lllPPENSTEEL, CASEY M
Patient #: 3182151
Admission Date: 02/16/2001
R E. Gorman, M,D.
Medical Record #: 518233
Patient Type: 1
DOB: 08/06/1986
Patient Rm: 0269-01
DIAGNOSIS:
SECONDARY DIAGNOSIS: Asthma.
IDS TORY OF PRESENT ILLNESS: This is a 14-year-01d unbelted, rear-seat, driver-side
passenger who was T -boned in an MY A, and the car was struck into a telephone pole on the
driver's side. She did lose consciousness, and she has amnesia about the events surrounding the
accident but none since, Her vital signs were stable in the field and en route. She is complaining
of some pain in her head, her left shoulder, her back throughout the thoracic and lumbar regions,
her right ankle and her left knee.
PAST MEDICAL IDSTORY: Her past medical history is significant for asthma.
ALLERGIES: She has allergies to penicillin.
MEDICATIONS: Her medications include Singulair and albuterol.
PHYSICAL EXAM:
GENERAL:
She is awake and alert. She is in no acute distress. Vital signs were stable.
HEENT:
Normocephalic. There is a laceration on her forehead just beneath the
hairline extending transversely that goes deep almost down to the galea.
Pupils are equally round and reactive. TMs are clear.
NECK:
Her neck is supple. Mildly tender posteriorly.
LUNGS/CHEST:
Lungs are clear.
HEART:
Heart is regular rate and rhythm.
ABDOMEN:
The abdomen was mildly tender in the right upper quadrant without
guarding or rebound.
-,
PELVIS:
Stable.
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HIPPENSTEEL, CASEY M
Acet: 318215-1 Rm/Bed: 0269/01
MR#: 518233 Adm Dt:02/16/01
Doctor: GORMAN MD, RICHARD E
DOB/Age: 08/06/86 14Y Sex: F
Notify: DIANNA 7175325538
IT' T THE CHAMBERS BURG HOSPITAL
'P1. 112 North Seventh Street. Chambersburg, PA 17201
:--. ........
GRAPHIC SHEET
P04060
Date:
~(,(,
Intake:
(24 hrs,)
Output:
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CbomI>onboq, PA 172111$ll . (717) 267.3000
HIPPENSTEEL, CASEY M
Acct' 318215.1 Rm/Bed: 0269/01
MRi 518233 Adm Dt:02/16/01
Doctor: GORMAN MD, RICHARD E
DOB/Age: 08/06/86 14YSex: F
Notify: DIANNA 7175325538
24 HOUR FLUlDINT AKE AND OUTPUT
(Record in c.c,)
P04310 (O:3/82,R:2193,R:6/97)
02/17/01, 003'
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Th -' lAMBERSBURG
P H Y SIC I A N S
From 026701 to
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SUM MAR Y
027202
-
PAGE 4
NRS ROOM/BD PATIENT NAME PAT# AGE SEX WGT HT ADMITTED
205 0269/01 HIPPENSTEEL, CASEY M 318215 14Y F 159 LB 0 IN 021601
DOCTOR ADMISSION DIAGNOSIS
CONNOR DO E, J MICHAEL MULT TRAUMA
ALL ERG I E S / D I SEA S E
S TAT E S
PENICILLIN ALLERGY
DESCRIPTION STR/UNIT RT & FREQUENCY START STOP
*** SCHEDULED ORDERS ***
SINGULAIR 10MG PO BEDTIME 02/16,21
ANCEF/KEFZOL lGM PB Q 8 HRS 02/16:21 02/17:05
*** NON-SCHEDULED ORDERS ***
PROVENTIL**MDI BY RT** 2PUF IH Q4H PRN 02/16,20
TORADOL 15MG IV Q6H PRN 02/16,20 02/21,19
PERCOCET / ENDOCET 1 TAB PO Q3H PRN 02/16,20 02/23,19
*** DISCONTINUED ORDERS ***
SYRINGE INJECTABLE lEA PB ONCE 02/16,20 02/16:20
**DIPHTHERIA/TETANUS 0,5ML
TORADOL 30MG IV ONCE 02/16,21 02/16:21
DATE TIME ROOM/BD PATIENT NAME
02/17/01 00,37 0269/01 HIPPENSTEEL, CASEY M
PA1'#
318215
-AGE
14Y
/
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112 North Seventh Street . P.o. Box 6005
Cbambersburg, PA 17201-6005 . (717) 267-3000
PHYSICIAN'S ORDERS
DATE
TIME USE BALL POINT PEN - PRESS FIRMLY.
PHYSICIAN'S ORDERS
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ALLERGIES
DIAGNOSIS
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HIPPENSTEEL. CA~~Y o'f69/01
Acct:31821~i R:d~ 01::02/16/01
MR#: 518 N MD RICHARD E
Doctor: GO~~ro6/86' 14Y Sex: F
DOB/Age, 7175325538
Notify: DIANNA
HEIGHT
WEIGHT
DIABETIC 0
NON.DIABETIC 0
AUTHORIZATION IS HEREBY GIVEN TO DISPENSE A THERAPEUTIC
ALTERNATE DRUG (AS RECOMMENDED BY THE PHARMACY
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WORDS - NO SUBSTITUTE
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t 12 North Seventh Street. P.O, Box 6005
Chambersburg, PA 17201-6005 . (717) 267-3000
PHYSICIAN'S ORDERS
DATE
TIME USE BALL POINT PEN - PRESS FIRMLY.
PHYSICIAN'S ORDERS
~
ALLERGIES
DIAGNOSIS
(
HIPPENSTEEL, CASEY M
Acct: 318215-1 Rm/Bed: 0269/01 ,
~R#: 518233 Adm Dt:02/16/01
octor: GORMAN MD, RICHARD E
~OB/Age: 08/06/86 14YSex' F
otlfy: DIANNA 717532553'8
f 01/-
HEIGHT
WEIGHT
DIABETIC 0
NON.DIABETIC 0
AUTHORIZATION IS HEREBY GIVEN TO DISPENSE A THEAAPEUTIC
ALTERNATE DRUG (AS RECOMMENDED BY THE PHARMACY
THERAPEUTIC COMMITTEE) UNLESS OTHERWISE INDICATED BY THE
WORDS - NO SUBSTITUTE
P04190 {O:OND,R:03JOOl
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Acct:318215-1 Rm/Sed: 0269/01
MR#: 518233 Adm Dt: 02/16/01 .~ . ana{{,t!~~fs~!.~~Heallh
Doctor: GORMAN MD, RICHARD E Physician Progress Notes
DOS/Age: 08/06/86 14YSex: F
Notify: DIANNA 7175325538
P04260{4/00)
,
I
I
HIPPENSTEEL, CASEY M I
Acct: 318215-1 Rm/Bed: 0269/01 I
MR#: 518233 Adm Dt: 02/16/01
Doctor: GORMAN MD, RICHARD E I
DOB/Age:08/06/86 14Y Sex: F J
(. Notify: DIANNA 7175325538 .
~.
PROGRESS NOTES
ADMISSION NOTE - REGULATIONS REQUIRE
THAT THIS BE COMPLETED WITHIN 24
HOURS OF ADMISSION.
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Admitting Diagnosis:
other Diagnoses/conditions:
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SIGNATURE OF PERSON DATE NOTIFIED: TIME NOTIFIED: NAME OF PERSON RECEIVING
MAKING THE CALL CALL:
SIGNATURE OF ATIENDING PHYSICIAN:
o STAT
o URGENT
o ROUTINE
Ordering physician to call consultant if consult needed within one hour
History and Physical on chart or attending physician call consultant if consult needed within 2 - 12 hours
Consult to be done within 24 hours
) OPINION ONLY
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REPORT OF CONSULTATION
HIPPENSTEEL, CASEY 1\1I.. _
Acet: 318215-1 Rm/Bed: 0269/01
MR#.: 518233 Adm Dt:02116/01
Doctor: GORMAN MD, RICHARD E
DOB/Age: 08/06/86 14Y Sex: F
Notify: DIANNA 7175325538
White Copy - Chart Yellow Copy - Consultant
P04275 (0:OND,R3/97)
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Modality
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OXYGEN LEGE'
TREATMFNT LEGEND
MEDICATION LEGEND
SFCRETION IHiEND
I. Mucomyst 4.0ml
2. Normal Saline 3.0 mJ
3. Alupent 03 ml
4. Albuterol 0.25 ml
5 Albuterol 0.5 ml
~^trovellt unit dose
7 Other: { . 75 y. f~"'?'- __
. Other: _____~_._"______
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HIPPENSTEEL, CA~~~"~nnturc ~~ ~ :r)~7<rv!.l r\
Acct: 318215-1 v'
MR#: 518233 l '\. JVl.".L.-v'
Date: 02/16/01
DOB/Age: 08/06/86 14YSex' F
Patient Phone: (717)532-5538 .
Amount: Color"
1- Large C - Clear
2 - M(~derate w- White
3 - Small Y - Ydlo....
A: Absenl B - Blood -
t - Thick tinged
'- (I-Thin G - Green
npc; P - Puruknt
roNon-'productive Cough
n/e: Nasal Cannula
OM: S'mp]~ Oxygen Mask
NRB: Non-rebrealherMask
VM: Venti-ma<;k (vcnluri)
CA: Cool Aerosol
# .
other:
MN: Medication
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Ncb~lIizer
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Pn:ssurc Brcathine.
IS: Im;L'ntivc Spiromctc;
BREATH SOUND
I. Clear
2. Diminished
3. Wheezing
4. Rhonchi
5. Cra,kles
6. ^bscnt
7. Stidor
L: Left
R: Right
Bi!: Bilateral
SPUTUM SPECIMEN
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L: Luken's Trap
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SX = Suction
NT: Na<:;al Trachc:al
0: Oral Suction
TL: Tracheal
PfJ0991 (O:3r99)
THE CtlAMBERSBURGROSPIT AL
112 N. SEVENTH ST.
CHAMBERSBURG P A 17201
Page 1
OPERATIVE REPORT
HIPPENSTEEL, CASEY M
Patient #: 3182151
Surgery Date: 02/16/2001
R E . Gorman, M.D.
Medical Record #: 518233
Patient Type: 1
DOB: 08/06/1986
Patient Rm:
PREOP DIAGNOSIS:
~/~
POSTOP DIAGNOSIS:
OPERATION: Repair oflaceration offorehead,
SURGEON: R E . Gorman, M.D.
INDICATIONS: The patient was in a motor vehicle accident, multiple abrasions and also a
concussion. She has a laceration of her forehead that measures approximately 7 cm in length.
PROCEDURE: The patient was prepped and draped. The skin was anesthetized with 1 %
lidocaine with epinephrine. The wound was irrigated out copiously with saline under pressure.
The skin was cleaned with hydrogen peroxide. The skin was then closed with interrupted 5-0
nylon sutures of either vertical mattress or mostly simple. She tolerated the procedure well.
Bacitracin ointment and clean dressings were applied. The head was wrapped. The patient
tolerated the procedure well and was admitted.
REG/rlr
D: 02/16/2001
T: 02/20/2001
~~~~
I); soia '5 ed
,>/,'71"1
CHAMBERSP~"RG HOSPIT ~
SUMMIT ~<\L TH CENTT''Q. ,
... , .
. Rhonda B, '.; Shreiner Wl'/a's Center
. Summit Diagnostic Services
RADIOLOGIST'S REPORT
(71';A) 267-7149
FINAL
Name: HIPPENSTEEL, CASEY M
Date Done: 02-16-2001
Ordering Diif: C,V,E,A, C, V, EMERGENCY
Nurs Stat: 205
Faculty Dr: M. D" THOMAS L, CARTER
Room no,: 026901
Admitting Diag: MULT TRAUMA
Rsn for Exm:
MR#:
TPD
ASSOC.
518233 ReqSeq: 998131
Date: 02-17-2001 Time: 0753
Transcriptionist: MH
Pat Class: 1
Date of Birth: 08-06-1986
Patient phone: 7175325538
ACCOUNT NO: 318215
** FINAL **
*** F/C: 14 ***
HISTORY:
14 YEAR OLD FEMALE SUSTAINED INJURIES FROM AN MVA,
2/16/01
LATERAL CERVICAL SPINE: A LATERAL VIEW OF THE CERVICAL SPINE SHOWS
A NORMAL ALIGNMENT AND STATURE OF THE CERVICAL VERTEBRAL BODIES,
THERE IS NO DISPLACEMENT NOTED AT THE UNCOVERTEBRAL JOINT,
IMPRESSION: A SINGLE VIEW OF THE CERVICAL SPINE DOES NOT SHOW
OVERT FRACTURE OR DISPLACEMENT,
PORTABLE CHEST: THE PORTABLE ERECT CHEST EXAMINATION SHOWS NORMAL
AERATION OF THE LUNG FIELDS, THERE IS NO INFILTRATE, PNEUMOTHORAX,
CONSOLIDATION, OR FLUID, THE CARDIOMEDIASTINUM IS NORMAL, THERE IS
NO OBVIOUS RIB FRACTURE,
IMPRESSION: THE PORTABLE ONE VIEW CHEST EXAMINATION IS
UNREMARKABLE,
PELVIS: AP VIEW OF THE PELVIS WAS TAKEN WITH THE PATIENT STILL ON
THE TRAUMA BOARD, PELVIS AND SI JOINTS ARE NORMAL, BOTH PROXIMAL
FEMURS ARE UNREMARKABLE,
IMPRESSION: NO OVERT FRACTURE OF THE PELVIS OR PROXIMAL FEMURS,
62020
723,1
61012
786,5
62170
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{/._ -L. A-c::;-
Signed by DR, THOMAS L, CARTER M, D,
-,
CHAMBERS~~'RG HOSPIT
", .: --.--.
SUMMIT. ,.,....-. AL TH CENT":"f!"
.. , " -,., ,. .~
. Rhonda Ii, . j~, Shreiner W," jrt' s Center
. Summit Diagnostic Services
RADIOLOGIST'S REPORT
(717) 267-7149
FINAL
Name: HIPPENSTEEL, CASEY M
Date Done: 02-16-2001
Ordering Dr: C,V,E.A, C, V, EMERGENCY
Nurs Stat: 205
Faculty Dr: M, D" ROBERT S PYATT
Room no.: 026901
Admitting Diag: MULT TRAUMA
Rsn for Exm:
TRAUMA AUTO ACCIDENT
OMNI 150 CC
Patient phone: 7175325538
MR#:
TPD
ASSOC,
518233 ReqSeq: 998220
Date: 02-16-2001 Time: 1820
Transcriptionist: DMS
Pat Class: 1
Date of Birth: 08-06-1986
ACCOUNT NO: 318215
** FINAL **
*** F/c: 14 ***
HISTORY: 14 YEAR OLD MALE, MVA,
2-16-01
CRANIAL CT: SOFT TISSUE SWELLING IS NOTED OVER THE FOREHEAD NEAR
THE VERTEX. THERE DOES NOT APPEAR TO BE EVIDENCE OF A SKULL
FRACTURE, INTRACRANIAL HEMORRHAGE, OR OTHER SIGNIFICANT ACUTE
ABNORMALITY.
IMPRESSION: NEGATIVE STUDY.
FACIAL BONES: AXIAL AND REFORMATTED CORONAL IMAGES DEMONSTRATE NO
EVIDENCE OF ORBITAL FLOOR FRACTURE THE ZYGOMATIC ARCHES ARE INTACT,
THERE IS NO EVIDENCE OF ORBITAL EMPHYSEMA. EXAMINATION IS
OTHERWISE UNREMARKABLE.
IMPRESSION: NORMAL FACIAL BONE CT,
CT ABDOMEN: CT SECTIONS WERE OBTAINED AFTER THE ADMINISTRATION OF
150 CC, OF OMNIPAQUE-300, ORAL CONTRAST WAS ALSO ADMINISTERED, THE
VISUALIZED PORTIONS OF THE LIVER, LUNG BASES, SPLEEN, GALLBLADDER,
AND PANCREAS ARE NORMAL. THERE IS NO EVIDENCE OF FREE
INTRAPERITONEAL AIR, OR FREE INTRAPERITONEAL FLUID, THE KIDNEYS ARE
NORMAL,
IMPRESSION: NORMAL ABDOMINAL CT,
CTPELVIS: CT SECTIONS WERE OBTAINED IN STANDARD TRANSAXIAL
PROJECTION AFTER THE ADMINISTRATION OF IV CONTRAST. THERE IS NO
EVIDENCE OF FREE INTRAPERITONEAL FLUID, THE BLADDER IS
CATHETERIZED, THE LATERAL PELVIC SIDEWALLS ARE UNREMARKABLE,
PRESACRAL SOFT TISSUES ARE ALSO NORMAL, THERE IS NO EVIDENCE OF
-, -
CI!AMBERS"''':1RG HOSPI1
~
SUMMIT. _____:AL TH CENT::>"'-R
. Rhonda t' .e Shreiner W ';n' s Center
. Summit Diagnostic Services
(717) 267-7149
RADIOLOGIST'S REPORT
FINAL
Name: HIPPENSTEEL, CASEY M
Date Done: 02-16-2001
MR#: 518233 ReqSeq: 998220
TPD Date: 02-16-2001 Time: 1820
ACUTE ABNORMALITY,
IMPRESSION: NEGATIVE PELVIC CT.
60450
959,1
60486 66375
64160
62193
;UJ.J.trJ~~
Signed by DR. ROBERT S PYATT M, D,
PAGE
2
-,
CHAMBERS:~"TR( f Hospr
-
SUMMr: ...."...-:AL TH CEN",~R
. Rhonda l.e Shreiner W In's Center
. Summit Diagnostic Services
RADIOLOGIST'S REPORT
(717) 267-7149
FINAL
Name: HIPPENSTEEL, CASEY M
Date Done: 02-16-2001
Ordering D~: C.V.E,A, C, V, EMERGENCY
Nurs Stat: 205
Faculty Dr: M.D" PHILIP J, SABRI
Room no.: 026901
Admitting Diag: MULT TRAUMA
Rsn for Exm:
MR#:
TPD
ASSOC,
518233 ReqSeq: 998162
Date: 02-16-2001 Time: 1718
Transcriptionist: DMS
Pat Class: 1
Date of Birth: 08-06-1986
Patient phone: 7175325538
ACCOUNT NO: 318215
** FINAL **
*** F/c: 14 ***
HISTORY: 14 YEAR OLD MALE INVOLVED IN MVA
2-16-01
CERVICAL SPINE: PORTABLE CROSS TABLE LATERAL EXAM DEMONSTRATES NO
EVIDENCE OF FRACTURE OR PREVERTEBRAL SOFT TISSUE SWELLING. NO MAL
ALIGNMENT IS NOTED,
CERVICAL SPINE (FULL SERIES) : OPEN MOUTH, AP, OBLIQUE, AND LATERAL
VIEWS DEMONSTRATE NO EVIDENCE OF FRACTURE OR MAL ALIGNMENT, NO SOFT
TISSUE SWELLING IS NOTED IN THE PREVERTEBRAL SOFT TISSUES, NO DISC
SPACE NARROWING IS NOTED,
LUMBOSACRAL SPINE: AP, LATERAL, OBLIQUE, LATERAL L5-S1 SPOT FILMS
DEMONSTRATE NO EVIDENCE OF FRACTURE OR COMPRESSION DEFORMITY OR DISC
SPACE NARROWING OR MAL ALIGNMENT. THERE IS A LARGE AMOUNT OF GAS
IN OVERLYING SMALL BOWEL LOOPS WHICH MAKES VISUALIZATION OF THE BONY
STRUCTURES SOMEWHAT MORE DIFFICULT.
IMPRESSION: NO FRACTURE DEMONSTRATED, PROMINENT OVERLYING GAS IN
NONDISTENDED SMALL AND LARGE BOWEL MAKES VISUALIZATION OF THE SPINE
SOMEWHAT LESS THAN OPTIMAL, THERE IS CONTRAST IN THE RENAL
COLLECTING SYSTEMS.
NEGATIVE STUDY WITH NO EVIDENCE OF FRACTURE,
OR BONY DESTRUCTIVE CHANGE,
LEFT ,--NE~AT E STUDY WITH NO EVIDENCE OF FRACTURE,
DISLOCATION, OR BONY DESTRUCTIVE CHANGE.
THORACIC SPINE: VERTEBRAL BODIES AND DISC SPACES ARE WELL MAINTAINED
IN GOOD HEIGHT AND ALIGNMENT, THERE IS NO EVIDENCE OF FRACTURE, OR
BONY DESTRUCTIVE CHANGE. THE ALIGNMENT IS NORMAL. SOFT TISSUES
ARE UNREMARKABLE.
IMPRESSION: NORMAL THORACIC SPINE,
-,
CHAMBERsr~G HOSPIT
~
SUMMIT.. --<' AL TH CENTr~
. . . ,:... \
. Rhonda B~ ; Shreiner We21's Center
. Summit Diagnostic Services
RADIOLOGIST'S REPORT
(717) 267-7149
FINAL
Name: HIPPEN&TEEL, CASEY M
Date Done: 02-16-2001
MR#: 518233 ReqSeq: 998162
TPD Date: 02-16-2001 Time: 1718
LEFT SHOULDER: NEGATIVE STUDY WITH NO EVIDENCE OF FRACTURE,
DISLOCATION, OR BONY DESTRUCTIVE CHANGE,
62050 62110 63610 562LT 62072 63030
959,1 959,6 952,0 952,1 959,7
P1Lj).aA1
Signed by DR, PHILIP J, SABRI M.D,
..
PAGE
2
-,
..,.,.....<
""'---"
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
NAME:
MR# ;
ACCT:
HIPPENSTEEL, CASEY M
518233
318215
AGE: 14Y
SEX: F
PHYSICIAN:GORMAN M.D.
DIAGNOSIS: MULT TRAUM
DISCHARGED:
LOCATION:
ROOM NO. :
RICHARD E.
02/17/20
2ND FLOOR
0269-01
WEST
************************************ COMPLETE BLOOD COUNT *************************************
DAY:
DATE:
TIME:
LOC:
1
02/16/01
1325
ECU
NORMAL
UNITS
- - -- - -- - -- - -- - -- - -- - -- - - - - - --- - -- - -- - -- - - - - -- - - -- - - - - - - - - - - - - - -- - - --- - - - - -- - - -- - - -- - - - - - - - - - - --
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
RDW
PLATELET
MPV
16.2 H 4-11 K/UL
4.73 3.8-5.4 M/UL
13.4 10.3-16.0 G/DL
40.0 35-40 %
85 85-95 CUMIC
28.3 27-32 MMG
33.5 32-37 %
13.2 %
293 150-400 K/UL
11.3 FL
9 0-11 %
69 20.0-70 .0 %
16 L 20-70 %
6 1-12 %
0 0-8.0 %
0 0.0-2.0 %
12.6 K/UL
2.6 0.8-4.4 K/UL
1.0 K/UL
0.0 0-0.6 K/UL
0.0 0.0-0.2 K/UL
NORMAL NORM.
ADEQUATE
PERCENT DIFFERENTIAL
BAND
NEUT
LYM
MONO
EOS
BASO
ABSOLUTE DIFFERENTIAL
NEUT
LYM
MONO
EOS
BASO
COMMENTS
RBC MORPHOLOGY
PLT ESTIMATE
-,
CONTINUED
HIPPENSTEEL, CASEY M
INPATIENT MEDICAL RECORDS ~OPY
Report ~rinted: 02/17/2001 j 22:01
.
ROOM NO.: 0269-01
PAGE: 1
--'
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX; F
PHYSICIAN: GORMAN M.D.
DIAGNOSIS: MULT TRAUM
NAME: HIPPENSTEEL, CASEY M
MR# : 518233
ACCT: 318215
-
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
****************************************** CHEMISTRY ******************************************
DATE:
TIME:
LOC:
02/16/01
1325
ECU
NORMAL UNITS
- - - - - - ~ - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
GLUCOSE
BUN
CREATININE
CALCIUM
SODIUM
POTASSIUM
CHLORIDE
TC02
AGAP
TOTAL PROTEIN
ALBUMIN
ALKALINE PHOSPHATASE
BILIRUBIN, TOTAL
GPT
GOT
AMYLASE
110
15
0.8
10.3
142
4.0
98 L
26
18 H
7.2
4.2
79
0.5
18
34
98
-,
CONTINUED
HIPPENSTEEL, CASEY M
INPATIENT MEDICAL RECORDS COPY
Report Printed: 02/17/2001 , 22:01
70-110 MG/DL
8-20 MG/DL
0.6-1.1 MG/DL
8.6-10.3mg/dL
135-145 mM/L
3.6-5.1 mM/L
101-111 mM/L
22-32 mM/L
5-15
6.1-7.9
3.4-4.8
<350
0.3-1.2
14-54
15-41
25-125
G/DL
G/DL
IU/L
MG/DL
IU/L
IU/L
IU/L
ROOM NO.: 0269-01
PAGE: 2
NAME: HIPPENSTEEL, CASEY M
MR# : 518233
ACCT: 318215
02/16/01
1325
. --
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX: F
PHYSICIAN: GORMAN M.D.,
DIAGNOSIS: MULT TRAUM
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
**************************************** BLOOD ALCOHOL ***************
BLOOD ALCOHOL
BLOOD DRAWN BY:
PREP USED:
COLLECTION SITE
TEST PERFORMED BY:
RESULT OF:
PLASMA/SERUM VALUE
SEAL INTEGRITY
~IPPENSTEEL,CASEY M
. .',VPATIENT MEDICAL RECORDS COPY
Repo_ : Printed: 02/17/2001 , 22: 01
Connie R. Harris, LPN
ALCOHOL PREP USED
RIGHT ARM
Linda Jean Sheffield,
[0]
NONE DETECTED
INTACT
CONTINUED.
-,
M,L.T. (ASCP)
%
ROOM NO.: 0269-01
PAGE: 3
.~
~~
NAME: HIPPENSTEEL, CASEY M
MR# : 518233
ACCT: 318215
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX; F
PHYSICIAN: GORMAN M.D.,
DIAGNOSIS: MULT TRAUM
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
***************************************** URINALYSIS ******************************************
DATE:
TIME:
LOC:
02/16/01
1318
ECU
NORMAL
UNITS
TYPE ING
COLOR YELLOW
CHARACTER CLEAR
GLUCOSE NEGATIVE NEG MG/DL
BILE NEGATIVE NEG
KETONES NEGATIVE NEG MG/DL
SPECIFIC GRAVITY 1.025 1. 003-1.026
BLOOD NEGATIVE NEG
PH 6.0 5. 0-8. 0
PROTEIN NEGATIVE NEG MG/DL
UROBILINOGEN 0.2 0 .1-1 .0 EU/DL
NITRITE NEGATIVE NEG
LEUKOCYTES NEGATIVE NEG
EPITHELIAL CELLS <l /HPF
- - -FOOTNOTES- --
LNG INFORMATION NOT GIVEN
~,
CONTINUED
HIPPENSTEEL,-CASEY M
INPATTENT MEDICAL RECORDS COPY
Report .Printed: 02/17/2001 , 22:01
ROOM NO.: 0269-01
PAGE: 4
TEST:
UNITS:
02/16/01
1318
TEST:
UNITS:
02/16/01
1318
~
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX: F
PHYSICIAN: GORMAN M.D.,
DIAGNOSIS: MULT TRAUM
NAME: HIPPENSTEEL, CASEY M
MR# : 518233
ACCT: 318215
*********************************** QUALITATIVE
AMPHETAMINES BARBITURATES
QUAL., URINE QUAL., URINE
NEGATIVE
NEGATIVE
=================================== QUALITATIVE
OPIATES PHENCYCLIDINE
QUAL., URINE QUAL., URINE
NEGATIVE
NEGATIVE
CONTINUED
HIPPEN~TEEL,CASEY M
INPATIENT MEDICAL RECORDS COpy
Report Printed: 02/17/2001 , 22:01
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
BENZODIAEPINE
QUAL. I URINE
TOXICOLOGY ************************************
COCAINE
QUAL. I URINE
NEGATIVE
NEGATIVE
TOXICOLOGY ====================================
CANNABINOIDS TRICYCLIC ANTIDEPRESSANT
QUAL. I URINE QUAL. I URINE
NEGATIVE
-,
NEGATIVE
ROOM NO.-: 0269-01
PAGE: 5
NAME: HIPPENSTEEL, CASEY M
MR# : 518233
ACCT: 318215
THE CHAMBERSBURG HOSPITAL
Department of pathology
(717) 267-7154
AGE: 14Y
SEX: F
PHYSICIAN: GORMAN M.D.,
DIAGNOSIS: MULT TRAUM
~
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
***************************************** COAGULATION *****************************************
DATE:
TIME:
LOC:
02/16/01
1325
ECU
NORMAL
UNITS
PROTIME
INR
11. 8
1.0
- - - - - -- -- - - - - - - - -- - --- - - - - - - - -- - -- - -- - - - - -- - - -- - - -- - - - - - - - - - -- - - -- - - - - -- - - - -- - -- - - -- - - - - - - - - ---
SEe
-,
CONTINUED
HIPPENSTEEL, CASEY M
INPATIENT MEDICAL RECORDS COPY
Report Printed: 02/17/2001 , 22:01
10.9-12.7
ROOM NO.: 0269-01
PAGE, 6
.~
NAME: HIPPENSTEEL, CASEY M
MR# : 518233
ACCT: 318215
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX: F
PHYSICIAN: GORMAN M.D.,
DIAGNOSIS: MULT TRAUM
---,.
ROOM NO.; 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
************************************** SEROLOGY-ROUTINE ***************************************
DATE:
TIME:
LOC:
02/16/01
1325
ECU
NORMAL UNITS
HCG
NEGATIVE
-----------------------------------------------------------------------------------------------
HIPPENSTEEL, CASEY M
INPATIENT MEDICAL RECORDS COPY
Report Printed: 02/17/2001 J 22:01
.-.,
CONTINUED
ROOM NO.: 0269-01
PAGE, 7
NAME: HIPPENSTEEL, CASEY M
MR# : 518233
ACCT: 318215
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX: F
PHYSICIAN: GORMAN M.D.,
DIAGNOSIS: MULT TRAUM
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
******************************* BLOOD TYPE AND ANTIBODY TESTING *******************************
02/16/01
1325
TYPE AND SCREEN (XM
ABO/RHIDI
ANTIBODY SCREEN
ARM BAND NUMBER
CONVE
A NEGATIVE
NONE DETECTED
R38174
--.,
CONTINUED
HIPPENSTEEL, CASEY M
INPATIENT MEDICAL RECORDS COPY
Report Printed: 02/17/2001 , 22:01
ROOM NO.: 0269~01
PAGE: 8
.
'-
NAME: HIPPENSTEEL, CASEY M
MR# ; 518233
ACCT: 318215
THE CHAMBERSBURG HOSPITAL
Department of Pathology
(717) 267-7154
AGE: 14Y
SEX: F
PHYSICIAN: GORMAN M.D. I
DIAGNOSIS: MULT TRAUM
ROOM NO.: 0269-01
LOCATION: 2ND FLOOR WEST
RICHARD E.
*************************************** CANCELLED TESTS ***************************************
02/16/01
CANCELLED: DIFFERENTIAL
REASON; MANUAL DIFFERENTIAL ORDERED
1325
END OF REPORT
HIPPENSTEEL, CASEY M
INPATIENT ~DICAL RECORDS COPY
Report Printed: 02/17/2001 I 22:01
ROOM NO.: 0269-01
PAGE: 9
Exhibit C
APR 05 2001 10:29 FR AUTO CALL SUPPORT
. FRAME: K 15
877 775 5001 TO 95825071
P,01/02
Wll. NATIONWIDE
~ ltt~~~~~R~
AUTO POLICV
DECLARATIONS
"Ig, , of 2
ThlSe Oocl"llIons arl I pal'! 01 thl policy nlmed lbOVl Ind IdlnlWltd by polICy num~r t..low They
SUpersedl Iny Ole/arlllons Iuuld ..~Ier, Vour poliCY pmvld.. thl CO\IIlIg.. ,nd IIm~1 shOWn In 1111
schadull 01 coverlgel, ThlY IPP/y 10 nch inlurad \'thlell as Indlcltad. Vour policy compll.. w~IIII1,
mOlorls,,' IIn.ncl.1 responslbRfty I,,,,, 01 your 11,11 only for ","let.. lor wlIlCII Propel'!y Dlmlgl ,nd ~o.lIy
Injury ~llbRny cOVIlIg.. .re provided.
Policy Number:
58 31 0 351'91
IlIuld:
JAN 11. 200'
PollcYIIOldtr:
(Namld InlllM)
DIANNA HIPPENSTEEL
213 NE I L ROAD
SH I PPENSBV~. P",
11251.9103
T/'II' ,0'''.'lllonl ~.g. wit'" the Policy Pl'O\il,IOl'll ll'lcf E"CIOtU1'l'\1I'IU eomDI".. ,'''''' Poflty. If\ C'OI'llICl.,.tlOn 01 "". 'Iym.'" 0' 1fl'
pr'f"'Il"'''' 1"0,,"," blIOw. ,folia polley II )..rtDy 11Illndld lOr I'" 'olley Period d"IClI'l11'Cl Th... o.OI"II~OtII WOltUd. III or,vlO,..
O.cll,.uon. *,,'U,., by Imlnel""ll'I\ or Oth.rw!U.
P....,Po<i....'IIO..' JAN \2, 2001 TO MAR 12. 2001
Pollc:y CANCEL.S 12'01 A.M 11 'h. Addr'" C1llrl, Nam,d ""I",rld un.,.. "ttIU'I
IMPORTANT MESSAGES:
THIS IS A CONTINl.OVS LIMITED POLICY.. REAO CAREFVl~V
UNLESS OTHERl'IISE STATED HEREIN I~) THE PuRPOSES FOR 'llHICH THE VEHiClE IS
TO ~ USED ARE 'P~EASURfHAND BUSI~S,S.' llU Tl-iE VEHICLE WI~~ g,~~
~RE~~~~~t'NC~O~ ~~TRlt.lh~'Ni5""'~PTION~TNM~ ~~~~~O
BAILMENT LEASE. CONDITIONAL SALEA PURCH.asE AGRE~~T~IoI:)RTOAGE OR OTl-lER
6~~~~W:hAi~5 ~~~?N!N~~~~"olH~~~~EM~~ tlJF EX~P~~<>1I~E UNLESS
PO~ICV DOES NOT COVER COL~ISION OAMAGE TO RENTED VEHIC~ES,
,
SEE ENC~OSEO NOTICE FOR PREMIUM DETAIL
Descrlpllon of Unit: THIS POllCV COVERS ONLY THE VEHICLE(SI OESCRIBED
'. 1985 WERe W~ROUIS 10 11a1"Weak4CB122178 Two Monlh
Cov..sg.. llmhlOlllsbllhy Premium
PROPERTY O..........GE ~ I AB I L I TY I ""8.~ $ 33,00
900ILV INJURY LIABILITY 50.00 P ON
UNINSURED MOTORIST 100.000 AAENCE $ 25,10
lS.000 "" P
uANOtHTACKI~ 30.000 EA RRENCE $ 3.20
OERINSUREO TORIST 15.000 EA~ ~ON
INON.STACKI~ 30.000 EA RRENCe $ 2.20
F RST PARTY BEFITS
OPTION 1.MEOICA~ BENEFIT S 10.000 S 22.60
FULL TORT
TOT"L S 86.40
C065 <'2/91)
r.p 'I\H'. r '"
RPR 05 2001 10:29 FR RUTO CRLL SUPPORT
& 1."...l.I....... _ ....,.
877 775 5001 TO 95825071
P,02/02
AUTO POLICY DECLARATIONS
Pogo 2 of 2
VEHICLE CLASSIFICATIONS
Premium ia Ba..d On,
, 985 MERe
PLEASURE
ADULT
PRI~IPAL
I.4ARRIED
USE OF VEHICLE
RATED DRIVER
APPLIED DISCOUNTS MULTI CAR
SPECIAL RATING .ULL TORT
Policy Form & Endonement" C046P C,430 C, 7 \'
Olllce Use, D 285609 281501
JAN '6. 2001
luued By: NATI()MI'IDE ASSURANCE COMPANY
Counlonlgned AI: HARR I SBU~. PA
By:R, DANGELLO
$
0.00
PO BOX 26S5
HARRIS aURG PA 171 05-2655
800-854-6645
LOSS AYABLE ENDORSEMENT
We ..RI pay loss or damage due under this policy according 10 your Intaresl end thet 01 the lIonholder, We may
maka saparata payments according 10 Ihose Interests.
We ..III pay Ihe lienholder lor a 108S undor Ihls policy even Ihough you hava violated Ihe terms of tM policy by
somelhlng you heve done or failed 10 do, However. ~ will not pay for any loss caused by conversIOn,
embezzlement or seerellon by you or anyone acting on your behalf,
W. ..III nol nOllfy the lIenholdar each time you renew this policy and wa may cancel this polley according to hs
terms, We will protect the lienholder's Inta"st fo, 10 days fro,!, tho dale "0 nollly hlln that the policy has
terminated, for any reason, II we pay Iha lienholder for any loss or damaga sunared during thaI' 0 day period, wo
havo the right 10 recove, the emount 01 ony such poymant l'om you.
II you lalllo gtvo procl 01 loss w~hln Iha tlma allowed, lha lIanholdar may protecl his Intoresl by fRlng a proof 01
10.. wtthln 30 deys a!ler Ihatllma,
Th. lienholder muSl notify us 01 any known change of ownership 0' Increase In the ,Isk, If he does not, he wtll not
be anlttlod to any payment under this andorsomenl.
II we pay Ihe lienholder under Iha ta,ms of Ihls endorsament for e loss not cOll8red under Ihe policy. we an
subrogaled to his rights egalnsl )'Ou, This will not 4NocI Ihe lIel\holdor's right to recover Ihe lull emount of his
clolm.iha lienholder must nslgn us his Intarest and Iranster to us allaupportlng documan!s, If we elOCllo poy the
balance due him on the vehicle,
In Ihose steles ..here we show a deducllble In e.cess of $250 for comprehensive ondlor collision Ihe lienholder
hos e S250 deductible lor comprehensive and/or collision In the ovenl of repossosslon,
LOSS PAYEE: Any los~ und,' ,;omprehOnslva or Ct'IJI.lon coll8'age provided on the "lI8rsa side Is poyoblo os
Inlerest n'l~1.oppear to ".mad InsllF1l\l and 1088 pa....., .-
FRAME: M 15
** TOTRL PRGE.02 **
02/19/2001 16:32
7175327151
REESE DANGELLO AGENY
PAGE 03
~
UHDERINSURBD MOTORIST COVERAGE AUTHORIZATION FORM
UIM 2
Please issue my policy with Underinsured Motorist Coverage limits of:
(Cannot exceed your Liability Coverage Limits or be less than Financial
Responsibility Limits.) Do not complete this form if your UIM limits
match your limits of Bodily Injury Liability.
Bodily Injury
Per person/per occurrence
~
$15,000/$30,000*
$25,000/SSO,000
$50,000/SlOO,000
$100,000/$300,000
$250,000/$500,000
$300,000/$300,000
$500,000/$500,000
*minimum limit
I:Ju~J~~j;"Q
Signature ' st Named Insured
policy Number 580357191
Date
C?'~2 ;;eoo
Agent R SUE
DANGELLO
County .\l;)J\)4~
Cwn~
JAN 24 1996 23:46
7175327151
PAGE,03
B2/19/2BB1 15:32
71 75327151
REESE DANGELLO AGENY
PAGE m
.-
RBJECTION OP STACKBD UNDERINSURED COVERAGE LIMITS
un<< 3
By signing this waiver I am rejecting stacked limits of under insured
motorist coverage under the policy for myself and members of my
household under which the limits of coverage available would be the
sum of limits for each motor vehicle insured under the policy.
Instead the limits of coverage that I am purchasing shall be reduced
to the limits stated in the policy. I knowingly and voluntarily
reject the stacked limits of coverage. I understand that my
premiums will be reduced if I reject this coverage.
J.LA~"~ ft';A/J~g
gnature F'i st Named Insured
'1tJ~d
/ Date
Policy Number 58D357191
Agent R SUE
DANGELLO
County ADAMS
JAN 24 1996 23:45
7175327151
PAGE,01
Exhibit D
MAR 29 2001 15:56 FR FSS
7158438688 TO 917175825071
P,04/11
Today's Date:
Name:
Date of Birth:
March 29, 2001
Casey Hippensteel
August 6, 1986
Female 'HT
Age: 14
Plan #2
Payable - 08-06-2004 (age 18),
Payable - 08-06-2007 (age 21),
LUMP SUM TOTALS:
Guaranteed
Amount: Cost:
$5,300 $4,500
$15,000 $10,500
$20,300 $15,000
$20,300 $15,000
Guaranteed Lumo Sum Benefits:
TOTAL STRUCTURE AMOUNT:
The Internal Rate of Return is approximately 5,75% and
the Tax Equivalent Yield is 8.21%, based on a 30% tax bracket
This proposal is effective through APRIL 9, 2001. This is the date that the funds for the
structure must be at the annuity company or this proposal will expire.
This is an illustration, not a contract.
(j
Exhibit E
RELEASE AGREEMENT
This Release Agreement ("Agreement") is entered into among Casey Hippensteel,
a minor, by her parents and natural guardians, Gary Hippensteel and Dianna
Hippensteel, Gary Hippensteel and Dianna Hippensteel, individually, and Colonial
Insurance Company (hereinafter collectively referred to as "the Parties"), The "Insured"
shall collectively mean Casey Hippensteel, a minor, by her parents and natural guardians,
Gary Hippensteel and Dianna Hippensteel, Gary Hippensteel and Dianna Hippensteel,
individually, their respective heirs, executors, administrators, personal representatives,
successors and assigns; and the "Insurance Company" shall mean Colonial Insurance
Company, its successors and assigns,
L RECITALS
A On or about February 16, 2001, at or near the intersection of Airport Road\T-
317 & Gilbert Road\State Route 3002, Southampton Township, Cumberland County,
Pennsylvania, Casey Hippensteel sustained personal injuries as a result of an automobile
accident (hereinafter referred to as the "Occurrence"), In connection with the Occurrence,
the Insured has asserted a claim against Colonial Insurance Company,
B. The parties desire to enter into this Agreement to provide, among other things,
for certain payments in full settlement and discharge of all claims and actions of the
Insured for damages arising out of or due to the Occurrence, on the terms and conditions
set forth herein, NOW THEREFORE, it is hereby agreed as follows:
II. UNDERINSURED MOTORIST RELEASE AGREEMENT
Know all men by these presents: That, for the promise to make the periodic
payments referred to in Paragraphs IVA(1) and (2) from the Insurance Company, the
Insured in his/her capacity as an insured does hereby forever release and discharge the
Insurance Company of and from all claims of whatsoever kind and nature prior to and
including the date hereof growing out of the Underinsured Motorist Coverage of an
Automobile Insurance Policy number 5837 D 357191, issued by the Insurance Company
to Dianna Hippensteel, and resulting from the Occurrence,
III. INJURIES KNOWN AND UNKNOWN
The Insured fully understands that the Insured may have suffered personal injuries
that are unknown to the Insured at present and that unknown complications of present
known injuries may arise, develop or be discovered in the future, including, but not limited
to, subsequent death or disability, The Insured acknowledges that the consideration
received under this Agreement is intended to and does release and discharge the
Insurance Company for any claims for, or consequences arising from, such injuries and
the Occurrence; and the Insured hereby waives any rights to assert in the future any
claims not now known or suspected even though, if such claims were known, such
knowledge would materially affect the terms of this Agreement
2
IV, PAYMENTS TO INSURED
A. Periodic Pavments. The Insurance Company hereby agrees to make the
following payments:
(1) To Casey Hippensteel ("Payee"), the following guaranteed lump sum payments:
Five Thousand Three Hundred Dollars ($5,300) on or about August 6, 2004,
Fifteen Thousand Dollars ($15,000) on or about August 6,2007,
(2) Should Casey Hippensteel die before August 6, 2007, then any remaining
guaranteed payments set forth in Paragraph IVA(1) shall instead be paid, as they
become due, to the estate of Casey Hippensteel, with the last guaranteed payment
to be made on or about August 6,2007.
(3) Casey Hippensteel shall have the right, after reaching the age of majority, to
submit a request to change the Beneficiary by filing a written request with the owner
of the annuity, This request will be reviewed by the owner of the annuity, and if
approved by the owner of the annuity and the issuing annuity company it will
become effective, Said request will be made in writing by Casey Hippensteel.
C, Nature of Pavments. All sums set forth in this Paragraph IV constitute
damages on account of personal injuries or sickness, arising from the Occurrence, within
the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended,
3
V. FINANCING OF PERIODIC PAYMENT OBLIGATION
A, Assiqnment of Obliqation, It is understood and agreed by and between the
parties hereto that the Insurance Company may, as a matter of right and in its sole
discretion, assign its duties and obligations to make such future payments as set forth in
Paragraphs IVA(1) and (2) to Hartford Comprehensive Employee Benefit Service Co.
pursuant to a "Qualified Assignment and Release Agreement," within the meaning of
Section 130(c) of the Internal Revenue Code of 1986, as amended, in the form attached
hereto as Exhibit A. Such assignment is hereby accepted by the Insured without right of
rejection and in full discharge and release of the duties and obligations of the Insurance
Company and all parties released by this Agreement with respect to such future
payments. If the Insurance Company assigns the duties and obligations as provided
herein, it is understood and agreed by and between the parties that Hartford
Comprehensive Employee Benefit Service Co, as the assignee, shall make said future
payments directly to the respective payees designated in Paragraphs IVA(1) and (2),
THE PARTIES HERETO EXPRESSLY UNDERSTAND AND AGREE THAT WHEN
AN ASSIGNMENT OF THE DUTIES AND OBLIGATIONS TO MAKE SAID FUTURE
PAYMENTS IS MADE BY THE INSURANCE COMPANY TO HARTFORD
COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO PURSUANT TO THIS
AGREEMENT, ALL OF THE DUTIES AND RESPONSIBILITIES OTHERWISE
IMPOSED UPON THE INSURANCE COMPANY BY THIS AGREEMENT WITH
4
RESPECT TO SUCH FUTURE PAYMENTS SHALL CEASE, AND INSTEAD BE
BINDING SOLELY UPON HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT
SERVICE CO. IT IS FURTHER UNDERSTOOD AND AGREED THAT WHEN AN
ASSIGNMENT IS MADE, THE INSURANCE COMPANY SHALL BE RELEASED FROM
ALL OBLIGATIONS TO MAKE SUCH FUTURE PAYMENTS AND HARTFORD
COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO SHALL AT ALL TIMES
REMAIN DIRECTLY AND SOLELY RESPONSIBLE FOR, AND SHALL RECEIVE
CREDIT FOR, THE FUTURE PAYMENTS. IT IS FURTHER UNDERSTOOD AND
AGREED THAT WHEN AN ASSIGNMENT IS MADE, HARTFORD COMPREHENSIVE
EMPLOYEE BENEFIT SERVICE CO ASSUMES THE DUTIES AND
RESPONSIBILITIES OF THE INSURANCE COMPANY WITH RESPECT TO SUCH
FUTURE PAYMENTS,
B. Third Party Pavment It is further understood and agreed by the parties that all
future payments as set forth in Paragraphs IVA(1) and (2) may, solely at the option of
the Insurance Company, or its assignee, Hartford Comprehensive Employee Benefit
SeNice Co, be financed by the purchase of an Annuity Contract from Hartford Life
Insurance Company (the "Annuity Contract"), When such an Annuity Contract is
purchased, the assignee, Hartford Comprehensive Employee Benefit SeNice Co shall be
the owner of the Annuity Contract and shall have and retain all rights of ownership in the
Annuity Contract For its own convenience, the assignee shall direct Hartford Life
Insurance Company to make all periodic payments directly to the respective payees
5
designated in Paragraphs IVA(1) and (2), Such payments will be applied against the
obligation of the Insurance Company or its assignee and shall operate as a pro tanto
discharge of the scheduled obligations set forth in this Agreement
C, Status of Insured, The Insured shall, at all times, remain a general creditor of
the Insurance Company or its assignee and shall have no rights in the Annuity Contract
nor in any other assets of the assignee. The Insurance Company or its assignee shall not
be required to set aside sufficient assets or secure its obligation to the Insured in any
manner whatsoever. The Insured acknowledges that the Insured has no right to receive
the present value of the payments due the Insured pursuant to Paragraphs IVA(1) and
(2), or to control the investment of, or accelerate, defer, increase or decrease the amount
of any payment required to be made to the Insured, The Insured shall only be entitled to
receive the payments specified in Paragraphs IVA(1) and (2), as they are due,
VI. NO CHANGES IN FUTURE PAYMENTS
Neither the Insured, his/her estate, nor any subsequent beneficiary or recipient of
any payments or any part of any payments under this Agreement, shall have the right to
accelerate, commute, or otherwise reduce to present value or to a lump sum any of the
payments or any part of any payments due under this Agreement
6
Neither the Insured, his/her estate, nor any subsequent beneficiary or recipient shall
have the right to transfer, assign, anticipate, mortgage, or otherwise encumber in advance
any payments or any part of any payments due under this Agreement
VII. ADEQUATE CONSIDERATION
The Insured agrees and acknowledges that the Insured accepts payment of the
sums that the Insured is to receive pursuant to this Agreement as a full, complete, final
and binding compromise of matters involving disputed issues regardless of whether too
much or too little may have been paid,
VIII. ENTIRE AGREEMENT
This Agreement contains the entire agreement between the Insured and the
Insurance Company with regard to the matters set forth herein. There are no other
understandings or agreements, verbal or otherwise, in relation thereto, between the
parties except as herein expressly set forth,
IX. READING OF AGREEMENT
In entering into this Agreement, the Insured represents that the Insured has
completely read all terms hereof and that such terms are fully understood and voluntarily
accepted by the Insured.
7
X. FUTURE COOPERATION
All parties agree to cooperate fully, to execute any and all supplementary
documents and to take all additional actions that may be necessary or appropriate to give
full force and effect to the terms and intent of this Agreement which are not inconsistent
with its terms,
XL DRAFTING OF DOCUMENT AND RELIANCE BY INSURED
This Agreement has been negotiated by the respective parties, The Insured
warrants, represents and agrees that the Insured is not relying on the advice of the
Insurance Company, or anyone associated with them as to the legal and income tax or
other consequences of any kind arising out of this Agreement Accordingly, the Insured
hereby releases and holds harmless the Insurance Company, and any and all counselor
consultants for them from any claim, cause of action or other rights of any kind which
Insured may assert because the legal, income tax or other consequences of this
Agreement are other than those anticipated by the Insured,
The undersigned, and each of them, warrant and represent that no promise,
inducement or agreement not herein expressed has been made to them and that this
Agreement constitutes the entire agreement between the parties hereto and that the
terms of this Agreement are contractual and not mere recitals.
8
The undersigned, and each of them, have read the foregoing Agreement and fully
understand it, and are aware of the propriety and legal effect of executing the same, and
neither the Agreement nor the compromise and settlement recited herein were induced
by fraud, coercion, compulsion or mistake, nor is this Agreement nor the compromise and
settlement made by the undersigned in reliance upon any statement or representation of
any of the parties hereby released, or their representatives, agents or attorneys,
XII. COURT APPROVAL
The Insured represents that the Insured has received any and all necessary court
approvals to enter into this Agreement
9
XIII. CONTROLLING LAW
This Agreement shall be construed and interpreted in accordance with the laws of
the Commonwealth of Pennsylvania.
Dated:
7 ~~j;C(j1
Dated: 7j~/-';:>Dl>1
Dated:
if~4 ~~/-);~
Gary ppenste,' vidually and as parent and
natural guardian of Casey Hippensteel, a minor,
Insured
~~~~LL
Dianna Hippen e~l, individually and as parent and
natural guardian of Casey Hippensteel, a minor,
Insured
Duly Authorized Representative for Colonial Insurance
Company
APPLICABLE TO PENNSYLVANIA ONLY:
For your protection, Pennsylvania requires the following to appear on this form: Any person
who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
10
POLICE INFORMATION ACCIDENT LOCATION I
\ INCIDENT H2.1177196 20, COUNTY Cumberland CODE 21
NUMBER
2. AGENCY Pennsylvania State Police 21 MUNICIPALITY Southampton -rwl' CODE 215
NAME
3 STATIONI Carlisle/2120 I 4 PATROL 21 PRINCIPAL ROADWA Y INFORMA TlON
PRECINCT ZONE
5 INVES' IGA TOA Jchn Litz . 't~ BADGE 8397 22 ROUTE NO. OR T 317 / Airport Rd.
Tpr. NUMBE R STREET NAME
5. APPROVED BV BACGE t.[j 2' SPEED 40 I 24. TYPE 0 25. ACCESS 1
CPL "'", "-. PALr1C/1.0 NUMBER L{ 9 LIMIT HIGHWAY CONTROL
7 INVESTIGATION 2/16/01 I 8. ARRIVAL 1221 INTERSECTING ROAD:
DATE TIME
ACCIDENT INFORMATION 26. ROUTE NO. OR SR 3002 / Gilbert Rd,
STREET NAME
51, ACCIDENT 2/16/01 10, DAY OF WEEK Friday 27. SPEED 40 I 28. TIPE 0 29. ACCESS 1
DATE LIMIT HIGHWAY CONTROl
'1, TIME OF 1200 12.. NUM8E:R 2 IF NOT A T INTERSECTION:
DAY OFUHITS
13 . Klll.s..o 1 ,.. f11INJ~REO 15. PRW, PROP. yn 'D. CROSS STREET OR
0 ACCICENT NI5<I SEGMENT MARKER
'6 010 VEHICLE HAve TO BE H. VEHICLE DAMAGE 0 31. DIRECTION N S E W ! 32. DISTANCE FT. MI.
O-NONE UNIT1 FROM SITE FROM SITE
REMOVED FROM THE SCENE? 33. DISTANCE WAS
UNIT 1 UNIT 2 ' -LIGHT 0 eSTIMATED n
2 _ MODERATE 0 MEASURED
yl2l NO yl2l NO 3.SE\lERE UN1T2 34. CONSTRUCTION PRINCPLE INTERSECTING
ZONE W J5 TRAFFIC D G
18 HAZARDOUS 19 PENNDOT CONTROL
MATERIALS yO N 121 PROPERTY yO N 121 DEVICE
UNIT# 1 UNIT # 2
36. LEGALLY Y N I 37. REG. BPW 5405 -j 38. STATE 56. LEGALLV Y N \ 37. REG. HS9017H I 38. STATE
PARKED? 0 0 PLATE PA PARKED? 0 0 PLATE PA
39. PA TITLE OR 43291409302 " PA Tine OR 50430161901DA
OUT.QF.sTATE \/IN OUT..QF-STATE VIN
40. O\NNE R Rose Ann Lauver <0. OlM\lER South Mountain Auto Sales
" O\NNER 1168 Means Hollow Rd. 4\1. OWNER 100 High Rd.
ADDRESS ADDRESS
<2 CITY, STATE Shippensburg, PA 17257 42. CllY, STATE Shippensburg, PA 17257
& ZIP CODE & ZIP CODE
4\3. YEAR I" MAKE " YEAR I" MAKE
1984 Dodce 1997 GMC
45. MODEL - (NOT Charger -148. INS. UNK 0 .6. MODEL - (NOT Jimmy I .~ i5<i UNK n
BODY TYPE) yl8l NO BODY TYPE) NO
47. BODY 03 "B. SPECIAL 0 "9. VEHICLE 2 ". eDDY 05 'B. SPECIAL 0 "9. VEHICI.E 2
TYPE USAGE OWN'f:RSHIP TYPE USAGE O\/VNERSHIP
50. INITIAL IMPACT 12 51. veHICLE 0 .2 TRAVEl. 35 so. INITIAL IMPACT 10 51, VEHICLE 0 '2. TRAVEL 35
POINT STATUS SPEED POINT STATUS SPEED
.,. VEHICLE 1 ... DRIVER 1 ... DRIVER 1 53. VEHICLE 1 .. QRIVER 1 55. DRIVER 1
GRAOIENT PRESENCE CONDmON GRADIENT PRESENCE CONDITION
... DRIVER 26593874 I 61 STATE ... DRIVER 25583256 157 STATE
NUMBER PA NUMBER PA
5B DRIVER Karen Renee Lauver ... DRIVER Austin John Myers
NAME NAME
.. DRIVER 1168 Means Hollow Rd. " DRIVER 777 Oakville Rd,
ADDRESS ADORESS
60 CITY. STATE Shippensburg, PA 17257 50. CITY, STATE Shippensburg, PA 17257
& ZIP CODE & ZIP CODE
61 SEX162, DATE OF 9/1/83 -1 63. PHONE 61. SEX I 62. DATE OF 3/30/81 I 63 PHONE
F B1RTH 530-9567 M U1RTH 776-7767
6". nMM. VEH. I 65. DRIVER C I 54. FlMM. VEH. (65. DRIVER C I
y N 181 CLA6S Y N 181 CLASS
61 CAARIER 67. CARRIER
6B CARRIER 58. CARRIER
ADDRESS ADDRESS
66 CITY, STATE 69. CITY. STATE
& ZIP CODE & ZIP CODE
10. USDDT" ICC' PUCM 70. USDOT" Ice, PUC.
72 VEH 73. CARGO 74. GW>IR 72. ViR "- CARGO 74. GVWR
CONFIG BODY TYPE CQNFIG BOOV TYPE
15. NO OF 75. HAZARDOUS 77. RELEASE DF HAZMAT 75. NO. OF 16. HAZARDOUS 77. riLEASE OF HAlMAT
AXLES MATERIALS yO NO UNK 0 AXLES MATERIALS Y NOUNKO
_/
...,,~
N~~
~
......
~
MMONWEALTH OF PENNSYLVA
POLICE ACCIDENT REPORT
~
REPORTABLE 121 NON-REPORTABLE 0
PACE 01
INVESTIGATING AGENCY
""....5(11195)
.
'RESPONDING EMS ....GENCY Curnt5erland Valley EMS, Life Won, Shlppensburg Hose INCIOENT. H2.1177196
~> MEOICAL F.e.CIlITY Carlisle Hospital, Hershey Medical Center ACCloeNT OATE 2/16/01
80. PEOPLE INFORMATION
A . C 0 e , G NAMe ADDRESS H I J K L M
1 1 F 17 3 9 0 Oper. /I 1 3 3 2 B 6 2
1 3 F 16 3 2 0 Mandy N. Grove P.O. Box 144 Newburg, PA 17240 2 3 9 B 6 1
1 4 F 14 3 2 0 Casey M. Hippensteel 243 Neil Rd. Shlppensbur9, PA 1725 4 2 2 B 6 1
1 6 F 13 3 2 0 Holly M. Lauver 1168 Means Hollow Rd. Shipp. PA 17257 0 0 0 B 6 0
2 1 M 19 3 2 2 Oper. /I 2 3 3 7 8 1 1
61 IllUMINATION Q 82. WEATHER Q 86 DIAGRAM 1=\""'''\' ite:~T Il ~
~ "T'\4_ ..
i'<>~1O !(
63 ROAD SURFACE ~ "\,__ II b .
'"
- - - / 1
84 PENNSYLVANIA SCHOOL DISTRICT I
(IF APP\'lCABLEJ ~,~ --[ I) ,I
NA """'iillC.~
,-, - -GJ
85 DESCRIPTION OF DAMAGED PROPERlY "<-~ ~
Tire Ruts, debris in field
,
, ,
O~ER Walter S. Burkholder ....." iQ.h 1\ :!.co::> ..,,,-'AIli~ 2D..
;, , 0- ~To?
ADDRESS it ,......
518 South Mtn. Estate Rd. ~ .-
~
PHONE 532-9373 rJ I
67_ NARRATIVE _IOENTIFY PRECIPITATING EVENTS, CAUSATION FACTORS, seQUENCE OF EVENTS, WITNESS STATEMENTS. AND PROVIDe ADDITIONAL DETAilS. UKE INSURANCE
INFORM'&' lION AND \.OCATION OF TOWED VEHICLES. IF KNOWN
Unit # 1 cell phone not present Unit # 2 cell phone present not in use,
This accident occurred as unit # 1 travelled SB on Airport Rd. and failed to stop at a properly posted stop
sign, Initial impact occurred as Unit # 1 entered the intersection with SR3002 and struck Unit # 2, which
was travelling EB, on the left side driver's door with its front end, The force of the collision spun unit # 1
into a counterclockwise rotation and forced Unit # 2 off the roadway where it landed in an adjacent field
and rolled over as the vehicle turned sideways. Unit # 1 came to a final rest facing WB partially on the
EB berm of High Rd. Unit # 2 came to a final rest facing NB and on its right side,
Physical evidence: debris field at point of impact, heavy front end damage of Unit # 1, heavy left side
damage of Unit # 2,
On 02/19/01 at approx 1500 hrs, this R.O, interviewed Oper # 1 via telephone, she related that she did
not remember anything about the accident and didn't know how it happened, Continued..
INSURANCE COMPANY State Farm Insurance INSURANCE COMPANY Erie Insurance Exchange
INFORMATION INFORMA TICN
UNIT POLICY 6853448B0538V UN!T POliCY q062580116
, NO. 2 NO.
NAME ADDRESS PHONE
., Glenn Edward Halter 940 Forest Court Carlisle, PA 17013 218-8905
Vv1TNESSES NAM~ .ADDRESS PHONE
69. VIOLATIONS INDICA TED 90 SECTION NUMBERS 10NI. Y IF CHARGEO) TC NTe
UNIT , Stop Signs & Yield Signs 3323 (b) !:8J 0
UNIT 2 None 0 0
91 PROSABlE 92. TYPE 93. RESUl T$ I:8J NO TEST 91, PROBABLE 92, TYPE 93. RESUlTS !:8J NO TesT 94. INve5T1GATlON
USE TEST o ReFuse u50 TEST o REFUSE COMPLETE?
UNIT 1 0 0 O. % DUNK UNIT2 0 0 O. % o UHK yes !:8J NO 0
-
AA"'S (11-95)
PAGe 02
1N~'(,o,,".~<.o. A~o.(
,
"";;:"
tfn
N1\ ~J
".
c-dMMONWEAL TH OF PENNSYL VA~
PAR CONTINUA TION SHEET
INCIDENT H2-11n'96 I ACCIOENT 2/16/0' ! COUNTY 21 MUNICIPAl. 215
NUMBER DATE CODE CODE
aD. PEOPLE INFORMATION USE OVERLAY' 2 SHEET FOR CODES
A . C 0 E f G NAME AOORESS H I J , L M
87. NARRATIVE
On 02/19/01 at approx, 1600 hrs, this R,O, interviewed Oper, # 2 via telephone, He related, I was
headed east bound to return the vehicle I was driving to the dealership that owned it. I wasn't real sure
where I was going so I wasn't going very fast, maybe around 35 MPH, I came up to the intersection and
saw the other car coming at me as I looked out my window and then I got hit.
On 02/21/01 at approx 1030 hrs this R,O interviewed the right front seat passenger, Mandy N, Grove,
via telephone, She related, We were on the way to my boyfriend's house coming back from school. As
we got closer to the stop sign I wondered to myself if she was going to stop, As we got to the stop sign it
was too late to say anything to her and we hit the other car, I think she may have slowed down but I'm
sure she didn't stop,
On 02/16/01 this R.O, interviewed the witness on scene, He related, I was right behind the GMC Jimmy,
he was going around 35 to 40 MPH and he got hit from the side by the girl driving the other car. She
completely ran the stop sign,
Both vehicles removed from scene by Chuck's Auto Repair, Shippensburg, PA
SP7-0015 Mailed to owners of Units 1 & 2,
89. DESCRIBE VIOLATIONS 90. SEI;;Tl0N NUMBERS (ONI. Y IF CHARGED) TC "TC
UI\IIT 1 0 0
UN1T2 0 0
91 PROBABLE 92. iYPE 53, RESULTS o NO TEST 91, PROBABLE 92. lYPE 93. RESUL T5 o NaTEST ~_ INVESTIGATION
USE TEsr o REfUSE USE TEST o REFUSE COMPLETE 1
UNIT 1 0, % DUNK UNIT2 O. % DUN' YES IZI NO 0
REPORTABLE IZI NON-REPORTABLE 0
PAGE,03
INVESTIGATING AGENCY
M--'l5C(11-95)
Exhibit A
Uniform Qualified Assignment and Release
Casey Hippensteel, a minor, by her parents and natural guardians, Gary Hippensteel and Dianna
Hippensteel
"Claimant"
"Assignor"
Colonial Insurance Company
Hartford Comprehensive Employee Benefit Service Co
"Assignee"
"Annuity Issuer" Hartford Life Insurance Company
"Effective Date"
This Agreement is made and entered into by and
between the parties hereto as of the Effective Date
with reference to the following facts:
A. Claimant has executed a settlement agreement or
release dated ' 2001 (the
"Settlement Agreement") that provides for the
Assignor to make certain periodic payments to or
for the benefit of the Claimant as stated in
Addendum No.1 (the "Periodic Payments"); and
B. The parties desire to effect a "qualified
assignment" within the meaning and subject to
the conditions of Section 130(c) of the Internal
Revenue Code of 1986 (the "Code"),
NOW, THEREFORE, in consideration of the foregoing
and other good and valuable consideration, the
parties agree as follows:
1. The Assignor hereby assigns and the Assignee
hereby assumes all of the Assignor's liability to
make the Periodic Payments. The Assignee
assumes no liability to make any payment not
specified in Addendum No.1.
2. The Periodic Payments constitute damages on
account of personal injury or sickness in a case
involving physical injury or physical sickness
within the meaning of Sections 104(a){2) and
130(c) of the Code,
3. The Assignee's liability to make the Periodic
Payments is no greater than that of the Assignor
immediately preceding this Agreement. Assignee
is not required to set aside specific assets to
secure the Periodic Payments. The Claimant has
no rights against the Assignee greater than a
general creditor. None of the Periodic Payments
may be accelerated, deferred, increased or
decreased and may not be anticipated, sold,
assigned or encumbered,
4, The obligation assumed by Assignee with respect
to any required payment shall be discharged
upon the mailing on or before the due date of a
valid check in the amount specified to the
address of record.
5. This Agreement shall be governed by and
interpreted in accordance with the laws of the
Commonwealth of Pennsylvania.
6, The Assignee may fund the Periodic Payments by
purchasing a "qualified funding asset" within the
meaning of Section 130(d) of the Code in the form
of an annuity contract issued by the Annuity
Issuer. All rights of ownership and control of
such annuity contract shall be and remain vested
in the Assignee exclusively.
7, The Assignee may have the Annuity Issuer send
payments under any "qualified funding asset"
purchased hereunder directly to the payee(s)
specified in Addendum No.1. Such direction of
payments shall be solely for the Assignee's
convenience and shall not provide the Claimant
or any payee with any rights of ownership or
control over the "qualified funding asset" or
against the Annuity Issuer.
8, Assignee's liability to make the Periodic
Payments shall continue without diminution
regardless of any bankruptcy or insolvency of the
Assignor.
9. In the event the Settlement Agreement is declared
terminated by a court of law or in the event that
Section 130(c) of the Code has not been satisfied,
this Agreement shall terminate. The Assignee
shall then assign ownership of any "qualified
funding asset" purchased hereunder to Assignor,
and Assignee's liability for the Periodic Payments
shall terminate.
10. This Agreement shall be binding upon the
respective representatives, heirs, successors
and assigns of the Claimant, the Assignor and
the Assignee and upon any person or entity that
may assert any right hereunder or to any of the
Periodic Payments.
11. The Claimant hereby accepts Assignee's
assumption of all liability for the Periodic
Payments and hereby releases the Assignor
from all liability for the Periodic Payments.
Assianor:
Colonial Insurance Companv
Assianee:
Hartford Comprehensive Emplovee Benefit Service Co
By:
By:
Authorized Representative
Authorized Representative
Title
Title
Claimant:
Gary Hippensteel as pare t and natural guardian of
Casey Hippensteel, a minor
Claimant:
Dianna Hipp nsteel, as parent a
Casey Hippensteel, a minor
Approved as to Fonn and Content:
By:
N/A
Claimant's Attorney
Addendum No.1
Description of Periodic Payments
The following payments:
(1) To Casey Hippensteel ("Payee"), the following guaranteed lump sum payments:
Five Thousand Three Hundred Dollars ($5,300) on or about August 6, 2004.
Fifteen Thousand Dollars ($15,000) on or about August 6, 2007.
(2) Should Casey Hippensteel die before August 6, 2007, then any remaining guaranteed payments set forth in
paragraph (1) shall instead be paid, as they become due, to the estate of Casey Hippensteel, with the last guaranteed
payment to be made on or about August 6, 2007.
(3) Casey Hippensteel shall have the right, after reaching the age of majority, to submit a request to change the
Beneficiary by filing a written request with the owner of the annuity. This request will be reviewed by the owner of the
annuity, and if approved by the owner of the annuity and the issuing annuity company it will become effective. Said
request will be made in writing by Casey Hippenste~1.
Initials
Claiman~#~
Claimant: ;j1r1.1i .
Assianor:
Assianee:
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NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY,
PETITIONER
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V,
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, as Parents and
Natural Guardians of CASEY
HIPPENSTEEL,
RESPONDENTS : 01-4659 CIVIL TERM
AND NOW, this
ORDER OF COURT
'11-
day of August, 2001, IT IS ORDERED that a
hearing shall be conducted on the within petition at 8:45 a,m" Monday, August 20,
2001, in Courtroom Number 2, Cumberland County Courthouse, Carlisle, Pennsylvania,
:saa
y
.,,/\
Amy L Coryer, Esquire
For Petitioner
VlNV^lASNN3d
AJ.Nnoo O~tlflH38f~no
r fJ :6 HlJ L - ~nv f 0
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NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY,
PETITIONER
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V,
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, as Parents and
Natural Guardians of CASEY
HIPPENSTEEL,
RESPONDENTS
01-4659 CIVil TERM
ORDER OF COURT
AND NOW, this
~
day of August, 2001, upon consideration of the
petition for leave to Settle or Compromise Minor's Action, it is hereby ordered that the
minor, Casey Hippensteel, born August 6, 1986, a minor through her parents and
natural guardians, Gary Hippensteel and Dianna Hippensteel, is authorized to enter into
a settlement agreement with the petitioner, Nationwide Assurance Company d/b/a
Colonial Insurance Company, for the minor child in the gross sum of Twenty Thousand
Three Hundred Dollars ($20,300,00), with a lump sun payment of Five Thousand Three
Hundred Dollars ($5,300,00) to be paid to Casey Hippensteel on or about August 6,
2004, and Fifteen Thousand Dollars ($15,000,00) to be paid to Casey Hippensteel on or
about August 6, 2007,
:saa
Edgar B, Bayl ,J,
,Y
W:.~~
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Amy L Coryer, Esquire
For Petitioner
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:n;;u-c:mittJJ.g :i petition to \vlthdra',;;,,: n10ne;.' fr0l11 my ;\illluit) Account. rh:s
lr '.'lj~'\ pU:T;'lEse~: caL lh:.:; <:2lf ! 2.tYl ddvir..g DC}I.\; is \ery t~-ns(~re. -;'-h,e he<idiig. ':ts ket:p
_ '1"1'..:: ctJ'u,ld mntor is re.lay to go and ti1ere are a lot ofc-Lh-:r tb:ngs d 'v'~l"onE \\;11:11
'"'_", -f 1 -','-'t:rc tCl fix this car:- would cost rHe (1 couple thousand doibrs a~ld j1"5 r:.c,t 'vnrth
,kHl"t ;ei:! tl-:at Llat this (l.lf "viJ] !i1t1ke i~~ thru the \-v'lnter v/lthou; causing an ~ccident.
1) '~~~_Uj't <l:f:Jfd ~o bu> a:ar straight OUt or put a dovvn p~~)'nlen: on one right IX)',,,; and
" 1 I d 1 i \ ., \. < . 1 h'
ace G1S3C e' anu cannot ne;p nle wltn tnJs. l ;;lfn trYIng ':0 eo tI,lS un ~llY ~)\\rn.
:)< \(T p1ense expiditc YOLr decision as soon as possible I vv'Guld real1y appn:.'('latt it.
Y'JL l~)r yuu tinl~ in this 1112tter.
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[v1. Hlppenste:~t
'-::~~ Neil Rd
i...;.h;;JI=K'nsburg. Pa i 7257
~. J. 7-477-8~28
o i -46SQ CJ\,"i.l Terrn
(\'1. 1-lippcnste,d
Petitioner
v
i\Jdti~"n\vide Assurance Company,
d(j/a Coioniai insurance Company
PETiTION FOR A GR~J'H OF MONEY HELD IN ANNliNlTY BY
HARTFORD INSURA.NCE COMPANY
1 . Petitioner is Casey M. Hippensteel. ! live at 243 Neil Rd Shippensburg, Pa
17257, Cumberland County, My birthdays August 6, 1986,
"
rhe settlement was entered by Iny n1001 and dad, Crary & Dianna Hlppens1~el on
.'
July 18,2001. Thru Post & Scheli, Pc,
'1 The cnu.rt order was approved on Augu.st 20, 200] in the court of common pleas
C'lmberland County, Pennsylvania. [t was signed by Judge Edgar B. Hailey.
--+. The settlcRi.ent fund is held in lilY narne until I tun) 21 years oid on August 6,
2u07. The total amount is $15,000.
:). i petition the courts to allow me to withdraw $5,OOOto purchase a vehicle,
c::m't afford to purchase one. ~1y vehicle is really getting unsafe and non't last
too much longer. I'd like to do this betore the weather gets Bad.
~ ~
6. I need the vehicle to get back and forth to \vork.
7 ! respectfully request a withdrawal of $5,000 to purchase a new vehicle and to
cover tax and transfer COStS.
8. Endos{.:d are SOTIle ~stimates c;f vehicles I have che..:ked 0::1, one is a pri\ratc
veh~ck.
Cl
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I have been stopped two days in a row Pennsylvania State Police because of a
defect in the lights 2.nd my motor is ready to blow up.
10. ltravel about 25 miks to work every clay. Then 25 miles home.
"
Respectfully yours,
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Casey M.Hippensteel
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1, Proposed Annuitant (Please Print)
Full Name /l I.
case en<sreeJ
Street Address nd
aLf3 Neil r')
City
0hi ensbur^
Tax ID/Social Security Number
170- U; -5077
Hni~ i'
. ,
Hartford Life Insurance Company
Hartford Life and Accident
,. '[ Insurance Company
'. artford, Connecticut 06115
Application For Annuity
Zip Code
Irt ;}57
Date 01 Birth (Month, Day, Year)
g-v-SLP
Place of Birth
2. Second Annuitant
Full Name
Sex
o Male 0 Female
Street Address
City
Zip Code
Tax ID/Social Security Number
Place of Birth
3. Contract Owner
Full Name
Hartford CEBSCD
Street Address
"
City
Hartford
I State CT
fuse,! Hl'ppen.:steel
I Zip Code
d
State
Ph
Zip Code
17~57
5.
tract will not be issued unless this question is answered)
o Life 0 Years Certain and Ufe
rRI Other: ex 1-um p .s urn s
6. Frequency of Annuity Payments: 0 Monthly [ZI Other
7, Amount of Each Annuity Payment:S 5,300
8. Annuity Payments to Commence: Month Day
8
9, Beneficiary (if r~uir ): Print Full Name I.
f '~Te.e..J
10, Does the Proposed Annuitan intend the replacement or change of any Annuity or Life Insurance in force in
any company with this application?
DYes r?J No (If yes, give details in 11)
11, Special Requests, Instructions and Details
L..urr. P c5Un-. S
<1$ 15, DOO 011
Year
dOD
8 - Lo - d.007
Relationship
"""' " ,j; ;WJtLJf
Proposed Annuitant:
Applicant:
{Jpj;1 ~.L
{;lti.a -
this 011/11 day of
. ---. - '"' "-0.-' ,_ ,,<' ...
.
CONTRACT SPECIFICATIONS
AGE AND SEX OF 15 FEMALE FIRST ANNUITANT CASEY IDPPENSTEEL
FIRST ANNUITANT
SECOND ANNUITANT N/A
AGE AND SEX OF
SECOND ANNUITANT N/A INCOME PAYMENT $5,300.00
DATE OF FIRST PAYMENT 08/06/2004 INCOME PAYMENT FREQUENCY ANNUAL
DATE OF ISSUE 11/0 l/200 J ANNUITY NUMBER CCX 23771
OWNER HARTFORD CEBSCO
SCHEDULE OF BENEFITS AND PREMIUMS
FORM NUMBERS
HL-
DESCRIPTION OF BENEF1T
SINGLE
PREMIUM
9353,942 J -1, 1I084-0
PAID IN FULL
.
SINGLE PREMIUM ANNUITY CERTAIN
LUMP SUM PAYMENTS
$ 5,300.00 ON 08/06/2004
$15,000,00 ON 08/06/2007
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HL-9353
Page 3
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"-',
NATIONWIDE ASSURANCE
COMPANY d/b/a COLONIAL
INSURANCE COMPANY
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
GARY HIPPENSTEEL AND DIANNA
HIPPENSTEEL, as Parents and
Natural Guardians of CASEY
HIPPENSTEEL
01-4659 CIVil TERM
ORDER OF COURT
AND NOW, this
DENIED.1
~
day of November, 2005, the within petition, IS
By th~~~/
~~
Edgar B, Bayley, J. ~~
~ey M. Hippensteel
243 Neil Road
Shippensburg, PA 17257
:sal
1 This was a structured settlement in which the last $15,000 that was placed into
an annuity is not payable until August 6, 2007,
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